Evolution Health Method Application Form
Personal Details
Full Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Current Health Statistics
Weight (kg)
Height (cm)
What is your biggest concern when it comes to your mental or physical health?
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Are you currently seeing a therapist or coach?
Yes
No
Is this the first time you hired a health coach or have you been with one before?
Yes
No
What motivates you to seek health coaching?
What are you goals and ambitions in life?
Please fill up the table below:
Yes
No
Occasional
Remarks/Notes
Difficulty of sleeping
Smoking
Drinking alcohol
Daily exercise
Surgical History
Drinking soda
Drinking caffeinated products
Are you currently taking any medications? If yes, please identify the medication name and purpose:
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Please check below if you have any of the current health conditions:
Present
Not Present
Remarks
Gastrointestinal
Respiratory
Cardiovascular
Neurological
Dermatological
Musculoskeletal
Urinary
Reproductive
Metabolic
Endocrine
What are the things or ways that you do to manage stress?
What relaxation techniques do you use?
If you'd like to add any relevant information, please do so here (or leave blank).
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