H E A L T H   H I S T O R Y

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

 
Date *
Date
Name: *
Name:
Phone: Home *
Phone: Home
Phone: Work *
Phone: Work
Phone: Mobile *
Phone: Mobile
Would you like your weight to be different? *
SOCIAL INFORMATION
HEALTH INFORMATION
Do you wake up at night? *
Do you grind your teeth? *
Pain in your jaw? *
WOMEN’S HEALTH
Are your periods regular? *
MEDICAL INFORMATION
FOOD INFORMATION
What foods did you eat often as a child?
FOOD INFORMATION
What is your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *
Do you cook? *
ADDITIONAL COMMENTS