Health History Intake FormAll of your information will remain confidential between you and the Health Coach. PERSONAL INFORMATION Name * First Name Last Name Email * How often do you check email? * Phone * (###) ### #### Age * Height * Current Weight * Weight 6 Months & 1 Year Ago * Would you like your weight to be different? If so, what? * SOCIAL INFORMATION Relationship status * Where do you currently live? * Children? Pets? * Occupation & hours of work per week? * HEALTH 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? * How is/was the health of your mother? * How is/was the health of your father? * What is your ancestry? * How is your sleep? How many hours? Do you wake up at night? Why? * Any pain, stiffness, or swelling? * Constipation/Diarrhea/Gas? * Allergies or sensitivities? Please explain * WOMEN'S HEALTH Are your periods regular? How many days is your flow? Painful or symptomatic? Reached or approaching menopause? Birth control history Do you experience yeast infections or urinary tract infections? Please explain DIET & EXERCISE Do you take any supplements or medications? * What role do sports and exercise play in your life? How frequent? * What was your diet like as a child? * 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? 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: * Anything else you would like to share? Thank you!