Health History Form All of your information will remain confidential between you and the Health Coach Personal InformationName* First Last Email* How often do you check your email?Main Phone*Work PhoneMobile PhoneAgeBirthdatePlace of BirthHeightCurrent WeightWeight 6 Months agoWould you like your weight to be different? If so, what weight?Social InformationRelationship StatusWhere do you currently live?ChildrenPetsOccupationHours per WeekHealth InformationPlease list your main health concernsOther 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?How is your sleep?How many hours?Do you wake up at night?If so, why?Any pain, stiffness or swelling?Constipation/Diarrhea/Gas?Allergies or sensitivities? Please explain:Women's HealthAre your periods regular?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 InformationDo 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 InformationWhat foods did you eat often as a child?BreakfastLunchDinnerSnacksLiquidsWhat is your food like these days?BreakfastLunchDinnerSnacksLiquidsWill 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:Additional CommentsAnything else you would like to share?Would You Like To Receive Emails From us in the Future?*YesNoNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.