All of your information will remain
confidential between you and the Health Coach.
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If you have already scheduled a consultation or are an existing client,
click the following links to fill out Revisit Form or your Health History form. Please be as detailed as possible so I can best assist you. 
​
Revisit Form

Women's Health History

Men's Health History

    revisit form

    All of your information will remain confidential between you and the Health Coach.
    Please answer the following questions so that I can better assist you:

    health information

    What are the positive changes you have noticed since your last session?

    How is your sleep?

    What are your main concerns at this time?

    Constipation or diarrhea?

    Any changes with weight?

    How is your mood?

    food information

    Are you cooking more?

    What foods do you crave?

    What is your diet like these days?

    ​- Breakfast
    - Lunch
    - Dinner
    - Snacks
    ​- Liquids

    women's health history 

    All of your information will remain confidential between you and the Health Coach.

    personal information:

    social information:
    First and Last Name

    Age and height

    Best form of contact; enter your email or phone

    Birthdate and place of birth

    Current weight and weight six months ago

    Would you like your weight to be different? If so, what?
    Relationship Status

    Where do you currently live?

    Children

    Pets

    Occupation

    Hours of work per week?

    health information:

    Food information:
    Please list your main health concerns/
    Other concerns and/or goals?

    At what point in your life did you feel best?

    Any serious illness/hospitalization/injuries?

    How is/was the health of your mother and father?

    What is your ancestry?

    What blood type are you?

    Any pain, stiffness or swelling?

    Constipation/Diarrhea/Gas?

    Allergies or sensitivities? 

    Are your periods regular? How Frequent?
    Painful or Symptomatic? Reached or approaching menopause? 

    ​​Birth Control History

    medical information

    Do you take any supplements or medications? 

    Any healers, helpers or therapies with which you are involved? 

    What role do sports and exercise play in your life?:

    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...

    ​

Men's Health History

All of your information will remain confidential between you and the Health Coach.

    personal information

    social information
    First and Last Name

    Age and height

    Best form of contact; enter your email or phone

    Birthdate and place of birth

    Current weight / weight six months ago / 1 year ago

    Would you like your weight to be different? If so, what?
    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?

    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

    medical information

    Do you take any supplements or medications? 

    Any healers, helpers or therapies with which you are involved?

    What role do sports and exercise play in your life?

    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?:
    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: