All of your information will remain confidential between you and the Health Coach.
First Name: * Last Name: * Email: *
Home Phone: Work Phone: Mobile Phone: Preferred Contact Method:
Age: Height: Birthdate: Place of Birth:
Current Weight: Weight six months ago: Weight one year ago: Would you like your weight to be different? If so, how?
Relationship status: Where do you currently live? Children: Pets: Occupation: Hours of work per week:
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 so, why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain:
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?:
What foods did you eat often as a child? 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:
Breakfast: Lunch: Dinner: Snacks: Liquids:
Anything else you would like to share?:
Please enter your full name to sign the form: