Health History Form

Personal Info

Name*

First Last

Email*

Phone*

Height*

Age*

Place of Residence*

Social Info

Relationship Status*

Children?*

Occupation*

Hours Worked Per Week*

Are you overwhelmed or frequently stressed out?*

Health Info

What is your biggest health challenge?*

What do you consider your healthiest habits?*

List your 3 top health and wellness goals.*

What is your biggest challenge meeting your goals?*

Your Bio Rhythms

What time do you do to bed and what time do you wake up?*

Do you sleep well? How many hours per night?*

How often do you exercise?*

What time of day do you exercise?*

What do you eat for breakfast at what time?*

What do you eat for Lunch at what time?*

What do you eat for Dinner and what time?*

If you snack, what do you eat? What time of day if so?*

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

What is one action you could do to today to improve your health?*

Is there anything else you would like to share with me?*

Thank you for taking the time answer these questions in support of your health and wellness. The information helps me begin to create your wellness plan and to prepare for our sessions. I look forward to connecting.