HEALTH HISTORY

Please answer the following questions as accurately and thoroughly as possible. All information will remain confidential between you and your health coach.
Name *
Name
Phone *
Phone
Mailing Address *
Mailing Address
Date of Birth *
Date of Birth
BASIC HEALTH INFORMATION
How do you feel about your current weight? *
HEALTH & LIFESTYLE INFORMATION
How happy are you with your overall health? *
How is your sleep? *
On average, how many hours per day are you physically active? *
Physical activity can include walking, jogging, hiking, biking, playing sports, working out, or manual labor.
How would you rate your current level of physical fitness? *
Give 2-3 examples for each meal of the day (breakfast, lunch, dinner, snack)
How many servings of vegetables do you typically consume daily? *
A standard serving is about 1 cup raw or cooked vegetables, or 2 cups raw green leafy vegetables.
How do you feel about your current eating habits? *
How many glasses of water do you consume daily? *
Glass = 16 oz. (a standard bottle of water is 16.9 oz. and a standard pint glass is 16 oz.)
Relationship status *
How do you feel about your job/career? *
How often do you feel stressed, anxious or worried? *
How often do you feel sad or lonely? *
HEALTH GOALS
How supportive will your friends and family be of your desire to make food and/or lifestyle changes? *
How do you feel about working with a health coach? *
How do you feel about working with a health coach?
Please answer as honestly as possible; there are no right or wrong answers!
I'm ready and excited to work with my coach.
I'm fully willing to do the work required to meet my goals.
I'm willing to hear new ideas from my coach and "try on" new concepts or different ways of doing things.
I will speak honestly with my coach.
If I feel that I am not getting what I need or expect from my coach, I will share this as soon as I sense it.
I'm willing to eliminate or modify behaviors which limit my success.
I see coaching as a worthwhile investment in my life.