HEALTHART-HEALTHCOACHING

Name:

Address:

Gender

Male Female Other

Telephone Number:

Email:

How often do you check your email:

Age:

Height:

Date of birth:

Place of birth:

Current weight in LB/KG specify:

Weight six month ago in LB/KG:

Weight one year ago in LB/KG:

Would you like your weight to be different?

If so, what?

Relationship Status:

Children:

Pets:

Occupation:

Hours of Work per Week:

Please list your health concerns:

Other concerns:

Any serious illness/hospitalization/injuries?

How is the health of your mother?

How is the health of your father?

What is your ancestry?

What blood type are you?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Reason for waking up at night?

Any pain, stiffness, or swelling?

Any allergies or sensitivities?

Please explain?

For women: Are your periods regular?

How many days is your flow?

How Frequent?

Painful or symptomatic?

Please explain:

Birth Control history:

Vaginal infections or reproductive concerns?

Constipation/Diarrhea/gas?

Please explain:

Do you take any supplements or medications:

Do you exercise?

What food did you eat often as a child?

What do you eat for breakfast, usually?

What do you eat for lunch, usually?

What do you eat for dinner, usually?

What do you eat for snacks, usually?

Do you drink a lot of liquids?

Do you drink water?

What percentage of your food is home cooked?

Will your friends or family support you?

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

Anything else you would like to share?

Note: The Form used was from Institute of Integrative Nutrition.

Refreshing

Vitamins

Healing

Empowering

Smile

Self Care

Nutrition

HEALTH HISTORY FORM