Revisit Form

Women's Health Form

Men's Health Form

All of your information will remain confidential between you and the Health Coach.

Personal Information

First name:

Last name:

Primary email address:

How often do you check your email?

Home phone:

Work phone:

Mobile phone:

Age:

Height:

Birthdate:

Month

Day

Year

Current weight:

Weight 6 months ago:

Weight 1 year ago:

Would you like your weight to be different, and by how much?

Social Information

Relationship status?

Where do you currently live?

Do you have children? If yes, how many?

Do you have pets?

Occupation?

How hours do you work per week?

Health Information

Please list your main health concerns:

Do you have 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 per night?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? 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?

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 diet like these days?
Breakfast?

Lunch?

Dinner?

Snacks?

Liquids?

Additional Comments

Anything else you would like to share?