Health History

This is the first step in your health history. Filling this form out will give your Health Coach valuable insight into how to help you succeed in your health and wellness goals.

Name *

First

Middle

Last

Email *

How often do you check email?

Daily, weekly, occasionally.

Numbers

Please provide a number where you can be reached.

What type of number is this?

Home, Work, Cell, if other please describe.

Age

Birthdate

mm/dd/yyyy

Place of birth

City, State, Country.

Height in feet and inches

Current Weight

Weight Six Months Ago

Weight One Year Ago

What is your goal weight?

Where do you currently live?

City, State, Country

Please tell me about your relationship with your parents.

Please tell me a little about your past and present relationships with romantic partners.

Relationship Status

Single, Married, Separated, Divorced, Widowed, It’s complicated.

Do you have children?

Please list names, how they are related to you, and their ages.

What is your relationship like with your children?

Do you have any pets?

What is the breed of your pets and what are their names?

How do you spend most of your day?

Attend school, go to work, work on hobbies, gone fishing, etc.

How many hours per week do you spend on school/work/hobbies, etc.?

Do you feel like you work too much, just enough, or need to find a greater challenge?

Please list your main health concerns.

Please expand a little.

Do you have other concerns or goals?

Many health coaches are capable of assisting with finances, relationships, spirituality and more.

At what point in life did you feel your best?

Any serious illnesses/hospitalizations/injuries?

Please tell me a little about each.

How is/was the health of your mother?

How is/was the health of your father?

What is your heritage/ancestry?

Common answers include Hispanic, Caucasian, African American, etc. but some people know more so this space is available for those who like to expand a bit.

What blood type are you?

How is your sleep?

Do you wake up at night? If so, why?

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas?

Any 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?

How active are you?

What foods did you eat often as a child?

Breakfast, lunch, dinner, snacks, and favorite beverages.

What foods do you eat most often now?

Breakfast, lunch, dinner, snacks, and favorite beverages.

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

• Yes
• No
• Maybe

Do you or someone else in the house cook?

• Yes, all the time
• Yes, sometimes
• Every once in a while
• Seldom
• No

What percentage of your food is home cooked?

Where do you get the rest of your food from?

Do you crave sugar, cigarettes, or have any addictions?

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

Is there anything else you'd like to share with your Health Coach?

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