Health History Form Please fill out the form below at least 24 hours before our session. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 7Confidentiality Notice: All information provided in this form is strictly confidential and will only be used for the purpose of our coaching sessions. Your privacy is of utmost importance, and I am committed to safeguarding your personal details and health information. By completing this form, you acknowledge and consent to the confidential handling of your data. PERSONAL Name *FirstLastLayoutAge *Height *Gender *FemaleMaleDetailsDate of Birth *Place of Birth *EmailEmail *Mobile Phone *Weight – 1Current Weight *Weight One Year Ago *Weight – 2 Would you like your weight to be different? *YesNoIf so, how?NextSOCIAL RelationshipRelationship Status *SingleIn a relationshipMarriedDivorcedWhere do you live? *DependentsChildren? *0123+Pets?WorkOccupation *How many hours do you work per week? *PreviousNextGENERAL HEALTH What are your main health concerns/goals? *At what point in your life did you feel your best? *Any current or previous serious illnesses, hospitalizations, or injuries? *LayoutHow is/was your mother’s health? *How is/was your father's health? *LayoutHow is your sleep? *How many hours do you sleep per night? *Do you wake up during the night? If so, why? *LayoutAny pain, stiffness, or swelling? *Any constipation, diarrhea, or gas? *Any allergies or sensitivities? *PreviousNextWOMEN’S HEALTH PeriodAre your periods regular? *YesNoHow many days is your flow? *How frequent? *Are your periods painful or symptomatic? If so, please explain: *Have you reached or are you approaching menopause? If so, please explain: *What is your birth control history? *Do you experience yeast infections or urinary tract infections? If so, please explain: *NextMEDICAL List all supplements or medications:Are you involved with any healers, helpers, or therapies? *What role do sports and exercise play in your life? *NextFOOD Will your family and friends be supportive of your desire to make food and/or lifestyle changes? *LayoutDo you cook? *YesNoWhat % of your food is home-cooked? *Where does your non-home-cooked food come from? *What foods did you eat often as a child? Child food 1Breakfast Breakfast 1 (child) *Breakfast 2 (child) *Breakfast 3 (child) *Lunch Lunch 1 (child) *Lunch 2 (child) *Lunch 3 (child) *Dinner Dinner 1 (child) *Dinner 2 (child) *Dinner 3 (child) *Child food 2Snacks Snacks 1 (child) *Snacks 2 (child) *Snacks 3 (child) *Liquids Liquids 1 (child) *Liquids 2 (child) *Liquids 3 (child) *What foods do you typically eat these days? Adult food 1Breakfast Breakfast 1 (adult) *Breakfast 2 (adult) *Breakfast 3 (adult) *Lunch Lunch 1 (adult) *Lunch 2 (adult) *Lunch 3 (adult) *Dinner Dinner 1 (adult) *Dinner 2 (adult) *Dinner 3 (adult) *Adult food 2Snacks Snacks 1 (adult) *Snacks 2 (adult) *Snacks 3 (adult) *Liquids Liquids 1 (adult) *Liquids 2 (adult) *Liquids 3 (adult) *Do you crave sugar, coffee, cigarettes or have any other major addictions? *What is the most important thing you should change about your diet to improve your health? *NextADDITIONAL COMMENTS Is there anything else you would like to share? *PreviousSubmit
