All of your information will remain confidential between you and the Health Coach.
How often do you check email?
Place of Birth
Would you like your weight to be different?
If so, why?
Where do you currently live?
Do you have children?
Do you have pets?
Hours of work per week
Please list main health concerns
Other concerns and/or goals
At what point in your life did you feel best?
Any serious illnesses, hospitalizations or injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestory?
What blood type are you?
O PositiveO NegativeA PositiveA NegativeB PositiveB NegativeAB PositiveAB NegativeNot Sure
How is your sleep?
How many hours?
Do you wake up at night?
Any pain, stiffness or swelling?
Constipation, diarrhea or gas?
Allergies or Sesitivities? Please explain:
Do you take any suppliements 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?
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
What is your food like these days?
Anything else you would like to share?