Health Coaching Intake Form 🩺
Provide your details to start your health coaching journey.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any current or past medical conditions?
Are you currently taking any medications or supplements?
Do you have any allergies?
How would you describe your current nutrition habits?
How often do you exercise?
Please Select
Rarely or never
1-2 times a week
3-4 times a week
5 or more times a week
How many hours of sleep do you get on average per night?
Please Select
Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
What are your primary health and wellness goals?
*
Current weight?
Weight a year ago?
At what point in life did you feel your best
Please describe your menstrual cycle
What do you eat for breakfast?
What do you eat for lunch?
What do you eat for dinner?
Any serious injuries or hospitalizations?
Any pain, stiffness, or swelling?
Do you experience yeast infections or urinary tract infections? If yes, please explain.
Any healers, helpers, or therapies in which you are involved with?
Constipation, diarrhea, gas, or bloating?
Do you cook?
Yes
No
What percent do you cook at home?
Please Select
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Is there anything else you'd like your coach to know?
Submit
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