Health History PERSONAL INFORMATION Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Age Sex Assigned at Birth Gender Identity Preferred Pronouns Occupation Home Address Prefered contact method Phone Text Email Mail Emergency Contact Name / Relationship / Phone Number HEALTH AND WELLNESS GOALS What are your health and wellness goals? Why are they important to you? What is/are your current challenges reaching your goals? What have you tried in the past to achieve your health goals? This includes any diets, fitness programs, coaches, supplements, courses, books etc. Have you ever seen a health coach in the past? If yes, when and why? Do you have any barriers that may impact your ability to follow a nutrition/lifestyle plan (such as, financial constraints, time constraints, etc.) PERSONAL HEALTH AND FAMILY HISTORY Health Information: What’s the most important thing you’d like to share about your health story? Do you have any of the following? If so, please list: • Primary care provider • Other physicians or specialists • Practitioners, therapists, healers, etc. Please list any supplements or medications you take: Have you experienced any barriers or challenges to accessing healthcare? Medical Information: Do you have any of the following? If so, please list: • Medical diagnoses or conditions • History of serious illnesses, hospitalizations, injuries, or surgeries Family History: Describe the health of your mother Describe the health of your father Is there anything from your childhood pertaining to your health you’d like to share? Do you have any other notable family or personal health information you’d like to share? PHYSICAL HEALTH INFORMATION Current weight Height How many hours do you sleep per night on average? How would you describe your quality of sleep? What is your energy level most days? 1 = Very Low | 5 = Very High 1 2 3 4 5 Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain: Do you have any of the following concerns? (Check all that apply.) Metabolic Health Blood Sugar Imbalances Elevated Blood Pressure Elevated Cholesterol Elevated Triglycerides Other Digestive Health Bloating Nausea Constipation Stomach Pain Diarrhea Gas Other How many bowel movements (on average) do you have per day? Reproductive Health Infertility Irregular Menstrual Cycle Low Libido Other Hormonal Health Thyroid Condition Toxin Exposure Signs or Symptoms of Hormonal Imbalance (please list below if any) Signs or Symptoms of Hormonal Imbalance Immune Health Autoimmune Conditions Low Vitamin D Level Frequent Illness or Infection Allergies and Sensitivities (please list below if any) Other Allergies and Sensitivities (please list) Brain Health Brain Fog Difficulty Concentrating Forgetfulness Other If you selected "Other" for any of the options above, please share them here NUTRITION INFORMATION What foods did you grow up eating? How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind? Describe your current relationship with food. Do you have any allergies or intolerances? If so, please list: Do any of the following apply to you? (Check all that apply) Challenges with Preparing Meals Difficulties Chewing or Swallowing Challenges with Access to Food Poor Appetite Do you regularly use any of the following? (Check all that apply) Alcohol Tobacco Products Other Substances Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain: What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories: Breakfast Lunch Dinner Snacks What, if anything, would you like to change about your nutrition? MENTAL AND EMOTIONAL HEALTH INFORMATION How would you describe your overall mental and emotional health? How do you like to support your mental health? How do you cope with stress? Have you meditated before? If so how many times would you meditate a day, week or month? Using a 1–5 scale (where 1 = never and 5 = always), rate how often you experience each of the following: Anger 1 - never 2 3 4 5 - always Excitement 1 - never 2 3 4 5 - always Fear 1 - never 2 3 4 5 - always Joy 1 - never 2 3 4 5 - always Love 1 - never 2 3 4 5 - always Sadness 1 - never 2 3 4 5 - always Stress 1 - never 2 3 4 5 - always Worry 1 - never 2 3 4 5 - always SPIRITUAL HEALTH INFORMATION What role does spirituality play in your life, if any? LIFESTYLE INFORMATION What are the important relationships in your life? Is there anything you’d like to share about your social life? If so, please explain: Who do you live with, if anyone? How many hours per week do you typically work? What hobbies or recreational activities do you enjoy? What role does movement, including sports, exercise, and physical activity, play in your life? ADDITIONAL COMMENTS Is there anything else you’d like to share? Thank you! Your health history has been submitted.
