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New Client - Holistic Health Coaching Information Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.
Would you like your weight to be different? Yes No
If so, what?
Hours of work per week:
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?
Do you sleep well? Yes No
How many hours?
Do you wake up at night? Yes No
Any pain, stiffness or swelling?
Are your periods regular? Yes No
How many days is your flow?
Painful or symptomatic? Please explain:
Constipation/Diarrhea/Gas? Please explain:
Allergies or sensitivities? Please explain:
Do you take any supplements or medications? Please list:
Any healers, helpers, or therapies which you are involved? Please list:
What role does sports and exercise play in your life?
Women Health Section
Reached or approaching menopause? Please explain:
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain:
What's your food like these days?
What foods did you eat often as a child?
What percentage of your food is home cooked?
Do you cook? Yes No
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should change about my diet to improve my health is: