Health History All of your information will remain confidential between you and the Health Coach. Personal InformationName* First Last Email* Enter Email Confirm Email How often do you check email?Home PhoneWork PhoneMobile PhoneYour Gender:MaleFemaleAgeBirth Date MM DD YYYY Place of BirthHeightCurrent WeightWeight Six Months AgoWeight One Year AgoWould you like your weight to be different?YesNoIf Yes: How would you like to see your weight changed?Social StatusRelationship StatusWhere do you currently live?Children?Pets?OccupationNumber of hours you work per weekHealth InformationPlease list your main health concernsOther concerns and/or goalsA what point in life did feel best?Any serious illnesses/hospitalizations/injuries?How is/was the health of your mother?How is/was the health of your father?What is your ancestry?What blood type are you?How is your sleep?How many hours?Do you wake up at night?YesNoIf Yes, why?Do you have any: Pain Stiffness Swelling Constiptation Diarrhea Gas Allergies or sensitivities Please ExplainAre your periods regular?YesNoHow many days is your flow?How frequent?Painful or symptomatic? Please explain:Reached or approaching menopause? Please explain:Birth control history:Do you experience yeast infections or urinary tract infections? Please explain:Medical InformationDo you take any supplements or medications? Please list:Any healers, helpers or therapies with which you are involved? Please list:What role do sports and exercise play in your life?Food InformationWhat foods did you eat often as a child for breakfast?What foods did you eat often as a child for lunch?What foods did you eat often as a child for dinner?What foods did you eat often as a child for snacks?What liquids did you drink often as a child?What is your food like these days? Breakfast:What is your food like these days? Lunch:What is your food like these days? Dinner:What is your food like these days? Snacks:What is your food like these days? Liquids:Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?YesNoUnknownDo you cook?YesNoWhat percentage of your food is home-cooked?Where do you get the rest from?Do you crave sugar, coffee, cigarettes, or have any major addictions?:The most important thing I should do to improve my health is:Additional CommentsAnything else you would like to share? This iframe contains the logic required to handle Ajax powered Gravity Forms.