Health Assessment Form
Your information will remain confidential between you and your Health Coach.
PERSONAL
Full Name
First Name
Last Name
Age:
Height:
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
City, State
Email Address
example@example.com
How often do you check your email?
Please Select
Daily
Weekly
Monthly
Contact Number
Phone Number
Format: (000) 000-0000.
Current Weight
In Pounds
Weight Six Months Ago
In Pounds
Weight One Year Ago
In Pounds
Would you like your weight to be different?
Please Select
Yes
No
If yes, how?
SOCIAL
Relationship Status
Please Select
Single
Married
Divorced
Engaged
In a Relationship
Complicated
Widowed
Open Relationship
Not Saying
Where do you live?
Any children?
Any Pets?
Occupation
How many hours do you work per week?
GENERAL HEALTH
What are your main health concerns?
Any other concerns and/or goals?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is/was your mother’s health?
How is/was your father’s health?
What is your ancestry?
What is your blood type?
How is your sleep?
How many hours do you sleep per night?
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any constipation, diarrhea, or gas?
Any allergies or sensitivities?
WOMEN’S HEALTH
Are your periods regular?
Please Select
Yes
No
How many days is your flow?
How frequent?
Are your periods painful or symptomatic? If so, please explain:
Have you reached or are you approaching menopause? If so, please explain:
What is your birth control history?
Do you experience yeast infections or urinary tract infections? If so, please explain:
MEDICAL
List all supplements or medications:
Are you involved with any healers, helpers, or therapies?
What role do sports and exercise play in your life?
FOOD
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Please Select
Yes
No
Do you cook?
Please Select
Yes
No
What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What foods do you typically eat these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
ADDITIONAL COMMENTS
Is there anything else you would like to share?
Signature
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