LIFE FORCE
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INTRO TO HEALTH COACHING
WHAT IS A HEALTH COACH
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Woman's Health History
Man's Health History
Revisit Form
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WomAn's Health History
All of your information will remain confidential between you and your VegEzy Health Coach. Fill this out to the best of your knowledge, if you don't feel like filling something out just pass on it. Only required Fields are name and email!
Personal Information
*
Indicates required field
Name
*
First
Last
What does your mama call you?
Email
*
Where can I email you back?
How often do you check e-mail:
*
Home Phone Number
*
Work Phone Number
*
Cellular Phone Number
*
Age
*
Height
*
Birthdate
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Date
*
Year
*
Place of Birth:
*
Current weight:
*
Weight six months ago:
*
One year ago:
*
Would you like your weight to be different?:
*
If so, what?:
*
Social Information
Relationship status:
*
Where do you currently live?:
*
Children:
*
Pets:
*
Occupation:
*
Hours of work per week:
*
Health Information
Please list your main health concerns:
*
Other concerns and/or goals?:
*
At what point in your life did you feel best?:
*
Any serious illnesses/hospitalizations/injuries?:
*
How is/was the health of your mother?:
*
How is/was the health of your father?:
*
What is your ancestry?:
*
What blood type are you?:
*
If you don't know that's ok
How is your sleep?:
*
How many hours?:
*
Do you wake up at night?:
*
Why?:
*
Any pain, stiffness or swelling?:
*
Constipation/Diarrhea/Gas?:
*
Allergies or sensitivities? Please explain:
*
Are your periods regular?:
*
How many days is your flow?:
*
How frequent?:
*
Painful or symptomatic? Please explain:
*
Reached or approaching menopause? Please explain:
*
Birth control history:
*
Do you experience yeast infections or urinary tract infections? Please explain:
*
Medical Information
Do you take any supplements or medications? Please list:
*
Any healers, helpers or therapies with which you are involved? Please list:
*
What role do sports and exercise play in your life?:
*
Food Information
What foods did you eat often as a
child?
Breakfast:
*
Lunch:
*
Dinner:
*
Snacks:
*
Liquids:
*
What is your food like these days?
Breakfast:
*
Lunch:
*
Dinner:
*
Snacks:
*
Liquids:
*
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
*
Do you cook?:
*
What percentage of your food is home-cooked?:
*
Where do you get the rest from?:
*
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
*
The most important thing I should do to improve my health is:
*
Additional Comments
Anything else you would like to share?:
*
Submit
Home
About
About Me
My Training
Work With Me
Health Coaching
>
Make an Appointment
INTRO TO HEALTH COACHING
WHAT IS A HEALTH COACH
My Approach
Forms
Woman's Health History
Man's Health History
Revisit Form
PRODUCTS
RECIPES
Breakfast
Lunch
Dinner
Juices & Smoothies
Spices & Condiments
FERMENTED FOODS
Blog
Contact Me
Newsletter
Store
Kombucha Kit