Health Coaching Questionnaire

Please write or print clearly. Your information will remain confidential between you and your Health Coach.

Personal

First Name(Required)

Last Name(Required)

Age(Required)

Height(Required)

Date(Required)

Place of Birth(Required)

Email(Required)

How often do you check your email(Required)

Home Phone(Required)

Work Phone(Required)

Mobile Phone(Required)

Current Weight(Required)

Weight Six Months Ago(Required)

Weight One Year Ago(Required)

Would you like your weight to be different, and if so, how?(Required)

Social

Relationship Status(Required)

Where do you live(Required)

Any children(Required)

Any pets(Required)

Occupation(Required)

How many hours do you work per week(Required)

General Health

What are your main health concerns(Required)

Any other concerns and/or goals?(Required)

At what point in your life did you feel your best?(Required)

Any current or previous serious illnesses, hospitalizations, or injuries?(Required)

How is/was your mother’s health?(Required)

How is/was your father’s health?(Required)

What is your ancestry?(Required)

What is your blood type?(Required)

How is your sleep(Required)

How many hours do you sleep per night?(Required)

Do you wake up during the night? If so, why?(Required)

Any pain, stiffness, or swelling?(Required)

Any constipation, diarrhea, or gas?(Required)

Will your family and friends be supportive of your desire to make food and/or lifestyle changes?(Required)

Medical

List all supplements or medications:(Required)

Are you involved with any healers, helpers, or therapies?(Required)

What role do sports and exercise play in your life?(Required)

Food

Will your family and friends be supportive of your desire to make food and/or lifestyle changes?(Required)

Do you cook(Required)

What percentage of your food is home-cooked?(Required)

Where does your non-home-cooked food come from?(Required)

What foods did you eat often as a child?(Required)

What foods do you typically eat these days?(Required)

Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?(Required)

What is the most important thing you should change about your diet to improve your health?(Required)

Additional Comments

Is there anything else you would like to share?(Required)

Health Coaching Questionnaire

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