Health History Form

The Coach will keep the Client’s information private, and will not share the Client’s information to any third party unless compelled to by law.

First Name

Last Name

Phone

Date of Birth

Place of Birth

Do you have any pets?

Where do you currently live?

Occupation

How many hours a week do you work?

Age

Height (ft)

Weight (lbs)

Are you taking any medications? If so please list

Do you have any allergies? If so, please list

Do you have any injuries or have you had any surgeries? If so please list

Any healer, helpers or therapist with which you are involved?

At what point in your life did you feel best?

What role do sports and exercise play in your life?

Are you taking any supplements? If so please list

Do you crave any sugar, coffee, or have any major addictions? If so please list

Do you drink coffee? If so, how often?

Do you eat out? IF so, how often?

What percentage of your food is home-cooked?

Breakfast

Lunch

Dinner

Snacks

Liquids