Health History Form
Please answer all possible questions below.
Personal Information
Full Name
E-mail
Cell Phone
Referred By
Age
Date of Birth
Gender
Female
Male
Height
Current Weight
Weight 6 Months Ago
Goal Weight, If Not Current?
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Social Information
Relationship status
Single
Married
In Relationship
Widow
Describe occupation
Hours of work per week
20-40
50-60
40-50
60+
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Health Information
Please list your main health concerns
At what point in your life did you feel best?
List any serious illnesses/ hospitalizations/ injuries
What time do you go to sleep at night?
How many hours per night do you sleep?
Do you wake up during sleep?
Yes
No
How is your sleep? Why do you wake up?
Do you wake rested?
Yes
No
Describe any pain, stiffness, swelling, constipation, diarrhea, gas, bloating
Nausea
Diarrhea
Heartburn
Indigestion
Constipation
Abdominal pain
Allergies or sensitivities?
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Medical/ Lifestyle Information
General
Please list any medications or supplements that you take as well as healers or therapies with which you are involved:
Describe the role that exercise plays in your life?
What are your major nutrition goals and why - such as improve performance (get faster or lift heavier), build muscle, lose fat, etc
What percentage of your food is home cooked?
None
25% - 50%
Less than 25%
50% - 75%
75%+
Please provide a current "day-in-the-life" of food, include any supplements/ shakes/ pre-workout, etc
Are there any food items that you cannot live without such as cheese, dark chocolate, yogurt, etc.
Please describe any other health concerns you may have (digestion, sleep, inflammation, bloating, etc) that were not listed previously
Please Sign: The Client expressly assumes the risks of the Program, including the risks of trying new foods, quantities or programs, and the risks inherent in making lifestyle changes. The Client releases the Coach from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against the Coach, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Coach
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