Health History Form

Thank you for agreeing to do a Health History with me.

It is important to fill out this form before we meet (whether in person or by phone), in order for me to familiarize with you and your health history.

All information entered here and whatever we discuss at our meetings will be treated with strictest confidence. No information will be shared with anyone without your consent.

I appreciate your taking the time to think through the answers to these questions. The more accurate/elaborate your answers, the easier we can possibly identify problem areas and work through it towards achieving your health goals.

Once again, thank you for trusting me with your personal information. Let me reiterate that this is a safe place for you to share openly. There will be no judgment whatsoever. πŸ™‚

I look forward to working with you to help you improve your overall health and well-being.

Oh … and in case you have not yet read about my health coaching service, please go here to understand why you need a health coach and what I offer with my program.

Your Health Coach,

  • PERSONAL INFORMATION

  • Please include country and area codes.
  • Please state town/city and country
  • SOCIAL INFORMATION

  • Please state significant other's name, if any.
  • Please state their names and age, if any.
  • HEALTH INFORMATION

  • Please state all the symptoms you are currently experiencing, even small ones like eye twitching.
  • Please state all known allergies and reactions you get when in contact with them.
  • Please state as detailed as possible, including time it happened, period of down time, medications, and whether it still has any impact on you now.
  • Please state (and number) your health goals in order of priority, and be as specific as you can.
  • Please mention health of father, mother, siblings and children.
  • Please state if you sleep well, hours of sleep, waking up at night, reason, and afternoon naps, if any.
  • Please be specific.
  • Please state if constipated, diarrhea, gas, bloating, indigestion, etc.
  • WOMEN'S HEALTH

    For the ladies only.
  • MEDICAL INFORMATION

  • FOOD INFORMATION

  • Please list the common foods you eat for Breakfast, Lunch, Dinner and between-meals.
  • Please state types of liquids, frequency and amount.
  • Please describe what you crave, amount and frequency of consumption.
  • Anything else you would like to share concerning your health, habits and lifestyle?

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