Health History
Fill in the form and I'll get back to you to schedule our first health coaching session, free of charge. The more detailed you are, the better, as it helps me structure our sessions. - Emelie
Full Name:
*
Date of Birth:
/
Day
/
Month
Year
Occupation:
Gender
Email Address:
*
example@example.com
Phone Number:
Please enter a valid phone number.
Preferred contact via:
Text
Email
Phone
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Health
All the information you can provide is helpful for our sessions.
Do you have a medical diagnosis or a history of serious illnesses, injuries or surgeries? If so, please list:
Please list any medications or supplements you take:
Do you have a family history of any particular illnesses? If so, please list:
Is there anything you would like to disclose about your health during childhood?
Your height:
Your weight:
Your blood type (if you know it):
Please Select
O
A
B
AB
Sleep Health
Sleep plays a big part in our health journey and is therefore important to discuss too.
How would you describe your sleep quality?
How many hours of sleep do you get per night? What time do you go to bed and what time do you wake up?
What is your energy level like most days?
Very low
Low
Moderate
High
Very high
Do you have any of the following?
Please tick all that apply.
Metabolic Health:
Blood sugar imbalance
High cholesterol
High blood pressure
High trigylcerides
Other
Digestive Health:
Bloating
Nausea
Constipation/Diarrhoea
Gas
Other
Hormonal Health:
Thyroid condition
Toxin exposure
Other signs or symptoms of hormonal imbalances
Immune Health:
Autoimmune conditions
Low level of vitamin D
Reoccurring infection or illness
Other
Brain Health:
Brain fog
Difficulty concentrating
Forgetfulness
Other
Reproductive Health:
Infertility
Irregular menstrual cycle
Low libido
PMS
Other
Do you have regular bowel movements from 1-3 times a day?
Yes
No
Nutrition Information
To understand more about your health today we need to take a glance at your childhood too.
What kind of food did you grow up eating?
Please describe your past and present relationship with food:
Is there anything you would like to change regarding your nutrition?
Do you feel challenged by any of the following? Please tick all that apply:
Challenges with preparing meals
Challenges with buying nutritious
Difficulties with chewing or swallowing
Poor appetite
Do you regularly use:
Alcohol
Tobacco
Other substances
Do you follow a specific diet? If so, please describe what kind:
Please list what a typical day of eating looks like for you. (e.g., breakfast, lunch, dinner and snacks):
Do you have any food allergies or intolerances? Please list:
Mental and Emotional Health
Taking care of our minds is just as important as our bodies but often pushed aside.
How would you describe your mental and emotional health?
In which ways do you support your mental health?
How do you cope with stress?
On a scale of 1-5, with 1 being never and 5 being always, how often do you feel:
Joy
Anger
Love
Fear
Stress
Sadness
Happiness
Worry
Lifestyle
Your everyday habits and lifestyle affect your holistic health too.
Which are the important realtionships in your life?
How is your social life? Are you more of an extrovert/introvert?
Do you live by yourself or with anyone else?
How many hours a week do you typically work?
Do you have hobbies?
How often do you move your body? (e.g., sports, exercise, physical activities)
Health Goals
What is it you dream of improving?
What would your like to work on regarding your health and wellness?
Sleep
Nutrition
Exercise
Stress Management
Mental Health
Mindfulness
Social Life
Managing Illness
Gut Health
Other
What, specifically, would you like to improve? What are your health and wellness goals?
Is there anything else you wish to share?
Submit
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