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Health History Intake Form

All of your information will remain confidential between you and the Health Coach. This form will take approximately 15 minutes to complete.

PERSONAL INFORMATION

Name

First Name

Last Name

How often to you check email?

Message

Home Phone:

(###)

###

####

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Age

Height

Birthdate

YYYY

Place of Birth

Current weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so, what?

SOCIAL INFORMATION

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

HEALTH INFORMATION

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you 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?

If yes, why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

WOMEN'S HEALTH

Are your periods regular?

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 INFORMATION

Do 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 INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

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:

DIET AND/OR EATING PROGRAMS TRIED IN THE PAST

Did or did they not work and why?

SPIRITUAL PRACTICE OR RELIGION

What is your current spiritual practice?

ADDITIONAL COMMENTS

Anything else you would like to share?