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How often do you check email? Date of Birth Gender Height Current Weight Six Months Ago One Year Ago Are You Happy with your current weight? Yes No If not, ideal weight: Relationship Status: Rate Relationship Health (1-10): Do you have children? Yes No Rate overall family relationships (1-10): Occupation: Work hours per week (include if stay at home parent): Are you happy with your job/career? Yes No Hobbies: Do you enjoy reading? Yes No Hours per week watching television: List your main health concerns: How is/was the health of your parents? What is your blood type? What is your ancestry? How is your sleep? How many hours? Do you wake up at night? Yes No List any allergies or sensitivities: List any serious illnesses and injuries including dates: List any prescription and non-prescription medications or natural supplements currently taking: List any doctors, healers or therapists you are current involved with: What kind of foods do you currently eat? Breakfast: Lunch: Dinner: Snacks: What percentage of your food is home cooked? How would you describe your relationship with food? List any cravings (ex. sugar, coffee) or other addictions: - What role does exercise play in your life? If 0 is not coping and 10 is feeling wonderful, how would you rate yourself: Today: Three months ago: One year ago: What was your main reason(s) for seeking out a health coach? What are some of the changes you would like to see in place throughout and beyond our coaching relationship? Is there anything else you would like to share about yourself or your overall health at this time?
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