Intake and Health History Form

Thank you for taking the time to fill out the Intake and Health History Form.

(All information will be kept confidential.)

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Email(Required)

Mobile Phone(Required)

Emergency Contact(Required)

Emergency Contact Number(Required)

Aspirations

What are you hoping to get out of coaching?(Required)

How would you like your habits or health to be different?(Required)

Health & Well-Being

What health problems or diagnoses have you been informed of?(Required)

What medications (prescription and over-the-counter) are you taking?(Required)

What supplements are you taking?(Required)

How would you rate your energy level? (scale of 1-10, 10 being highest)(Required)

How would you rate your stress level? (scale of 1-10, 10 being highest)(Required)

How do you manage stress?(Required)

How would you describe your physical activity/movement?(Required)

How would you describe your eating style?(Required)

Are there any foods you avoid due to preference, allergies, or intolerances?(Required)

How would you describe your relationship to food?(Required)

Do you experience regular gas, constipation, diarrhea, bloating, nausea, or heartburn?(Required)

Are you currently under a doctor and/or a mental health provider’s care? If yes, please describe briefly.(Required)

Are you experiencing any stresses, mood conditions, relationship difficulties, or substance-related conditions for which you would like resources or a confidential referral? If so, please describe briefly.(Required)

Is there anything else related to your health history that you think I should know?(Required)

Questions or Additional Information(Required)