Health HistoryAll of your information will remain confidential between you and the Health Coach. Date * MM DD YYYY Name: * First Name Last Name Email Address: * How often do you check email? * Phone: Home * (###) ### #### Phone: Work * (###) ### #### Phone: Mobile * (###) ### #### Age: * Height: * Birthday: * Place of Birth: * Current weight: * Weight six months ago: * Weight one year ago: * Would you like your weight to be different? * Yes No 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? * What blood type are you? * O A B AB How is your sleep? * How many hours? * Do you wake up at night? * Yes No Why? * Any pain, stiffness, or swelling? * Constipation/Diarrhea/Gas? * Allergies or sensitivities? Please explain: * Date of last dental exam: * Do you grind your teeth? * Yes No Pain in your jaw? * Yes No On a scale from 1 to 10, what is your current stress level? * 1 2 3 4 5 6 7 8 9 10 On a scale from 1 to 10, what is your current overall level of satisfaction with your life? * 1 2 3 4 5 6 7 8 9 10 On a scale from 1 to 10, how would you rate your self-esteem? * 1 2 3 4 5 6 7 8 9 10 On a scale from 1 to 10, how would you rate your self-confidence? * 1 2 3 4 5 6 7 8 9 10 WOMEN’S HEALTH Are your periods regular? * Yes No How many days is your flow? How frequent? * Painful or symptomatic? Please explain: * Reached or approaching menopause? Please explain: * Birth control history: * Do you experience yeast infections or urinary tract infections? 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: * FOOD INFORMATION What is your food like these days? Breakfast: * Lunch: * Dinner: * Snack: * Liquids: * Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? * Yes No Do you cook? * Yes No What percentage of your food is home-cooked? * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 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: * ADDITIONAL COMMENTS Anything else you would like to share? Thank you and congratulations on taking your first step towards balance. I will get back to you shortly!Onwards & Upwards,Carolina R. Marrelli, I.N.H.C.