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: Male Female Age Birth Date Month Day Year Place of Birth Height Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? Yes No If Yes: How would you like to see your weight changed?Social StatusRelationship Status Where do you currently live? Children? Pets? Occupation Number of hours you work per week Health InformationPlease list your main health concernsOther concerns and/or goalsAt what point in your life did you feel your 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? Yes No If Yes, why?Do you have any: Pain Stiffness Swelling Constiptation Diarrhea Gas Allergies or sensitivities Please ExplainAre your periods regular? Yes No How 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? Yes No Unknown Do you cook? Yes No What 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?
