Female Health History

Name: *

Please list any healers, helpers or therapies with which you are involved.

Constipation/Diarrhea/Gas?

Occupation

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

Any pain, stiffness or swelling?

How is/was the health of your mother?

What do you eat for breakfast?

What foods did you eat often for dinner as a child?

Other concerns and/or goals:

Men's Health History Form

All of your information will remain confidential between you and your health coach.

Please complete the form below (fields marked "*" are required) and click submit

Do you have any allergies or sensitivities? Explain

How often do you check your email?

Current Weight

Any serious illnesses/hospitalizations/injuries?

Would you like your weight to be different? Explain

Where do you get the rest from?

Home Phone *

Do you take any supplements or medications? Please list

What do you eat for dinner?

What do you eat for lunch?

What foods did you eat often for lunch as a child?

Relationship Status

Single

Married

Divorced

Children

What liquids did you drink often as a child?

Cell Phone

What is your blood type?

Where do you live?

Email: *

What do you eat for snacks?

How is/was the health of your father?

Height

Hours of work per week

At what point in your life did you feel best?

What liquids do you drink?

Date of Birth *

Please list your main health concerns:

The most important thing I should do to improve my health is:

What foods did you eat often for snacks as a child?

What percentage of your food is home-cooked?

Do you crave sugar, coffee, cigarettes or have a major addiction? Explain

Weight 1 yr ago

What foods did you eat often for breakfast as a child?

Do you cook?

Pets

Weight 6 months ago

Additional Comments - Anything else you would like to share?

How is your sleep? How many hours do you typically sleep a night? Do you wake up at night? Please explain

What role do sports and exercise play in your life?