All of your information will remain confidential between you and the Health Coach. Personal Information Your First Name (required) Your Last Name (required) Cell Phone (required) Your Email (required) How often do you check e-mail: ---1-5 a day6-10 a day11 or more times a day Age Height Birthdate Place of Birth Current weight Weight 6 months ago Weight 1 year ago Would you like your weight to be different? ---YesNo If so, what would you like your weight to be? Social Information Relationship Status ---MarriedSingleDivorcedWidow Where do you currently live? Children ---YesNo Pets ---YesNo Occupation Hours of work per week Personal 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? ---YesNo If so list serious illnesses/hospitalizations/injuries? How is/was the health of your mother? ---ExcellentVery GoodGoodFairPoor How is/was the health of your father? ---ExcellentVery GoodGoodFairPoor What is your ancestry? What blood type are you? How is your sleep? ---ExcellentVery GoodGoodFairPoor How many hours? Do you wake up at night? ---YesNo Why? Any pain, stiffness or swelling? ---YesNo Constipation/Diarrhea/Gas? ---YesNo Allergies or sensitivities? Please explain: Are your periods regular? ---YesNo 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? ---YesNo Do you cook? ---YesNo 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 Additional Comments Anything else you would like to share?