integrative coaching your health history Please complete the form below in as much detail as possible. SECTION 1: PERSONAL INFORMATION Name * First Name Last Name Date Of Birth MM DD YYYY Occupation Email * Phone (###) ### #### Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Method of Contact Phone Text Email Mail Emergency Contact Please provide NAME and RELATIONSHIP Emergency Contact Phone (###) ### #### SECTION 2: HEALTH AND WELLNESS GOALS What are your health and wellness goals? Why are they important to you? SECTION 3: PERSONAL HEALTH AND FAMILY HISTORY What's the most important thing you'd like to share about your health history? DO YOU HAVE ANY OF THE FOLLOWING? IF SO, PLEASE LIST. PRIMARY CARE PROVIDER OTHER PHYSICIANS OR SPECIALISTS PRACTITIONERS, THERAPISTS, HEALERS ETC. PLEASE LIST ANY SUPPLEMENTS OR MEDICATIONS YOU TAKE HAVE YOU EVER EXPERIENCED BARRIERS OR CHALLENGES ACCESSING HEALTHCARE? DO YOU HAVE ANY OF THE FOLLOWING? IF SO, PLEASE LIST. MEDICAL DIAGNOSES OR CONDITIONS HISTORY OF SERIOUS ILLNESS, HOSPITALIZATIONS, INJURIES OR SURGERIES FAMILY HISTORY DESCRIBE THE HEALTH OF YOUR MOTHER FATHER IS THERE ANYTHING PERTAINING TO YOUR CHILDHOOD HEALTH YOU'D LIKE TO SHARE? DO YOU HAVE ANY THER NOTABLE FAMILY OR PERSONAL HEALTH INFORMATION YOU'D LIKE TO SHARE? IF SO, PLEASE SHARE BELOW. SECTION 4: PHYSICAL HEALTH INFORMATION CURRENT HEIGHT CURRENT MEASUREMENTS If known bust, waist, abdomen, hips and any other measurements you track or see important to note. Body Weight If known, share. Also share how often you track, if at all. SLEEP HABITS How many hours do you sleep nightly, and how would you describe the quality of your sleep? How would you describe your energy most days? Very Low Low Average High Very High Do you experience any pain, stiffness, or swelling on a regular basis? if so, please explain. Do you have any of the following concerns? (check all that apply) Metabolic Health Blood Sugar Imbalances Elevated Blood Pressure Elevated Cholesterol Elevated Triglycerides Other Digestive Health Bloating Constipation Diarrhea Gas Nausea Stomach Pain Other How many bowel movements (on average) do you have per day? Reproductive Health Infertility Irregular Menstrual Cycle Low Libido Other Hormonal Health Thyroid Condition Toxin Exposure Signs or symptoms of Hormonal Imbalance Immune Health Autoimmune Conditions Frequent Illness or Infection Low VItamin D Level Allergies and Sensitivities Other Brain Health Brain Fog Difficulty Concentrating Forgetfulness Other Please share below any additional information where "other" was listed. SECTION 5: NUTRITION INFORMATION WHAT TYPES OF FOODS DID YOU EAT GROWING UP? HOW WOULD YOU DESCRIBE YOUR PAST RELATIONSHIP OR HISTORY WITH FOOD? DO ANY SPECIFIC MEMORIES ABOUT FOOD OR EATING COME TO MIND? DESCRIBE YOUR CURRENT RELATIONSHIP TO FOOD. DO YOU HAVE ANY FOOD ALLERGIES RO INTOLERANCES? IF SO, PLEASE LIST: DO ANY OF THE FOLLOWING APPLY TO YOU? (CHECK ALL THAT APPLY) Challenges with Preparing Meals Challenges with Access to Food Difficulties Chewing or Swallowing Poor Appetite Do you regularly use any of the following? (Check all that apply) Alcohol Tobacco Products Other Substances DO YOU FOLLOW A SPECIFIC EATING APPROACH/PRACTICE FOR PERSONAL, HEALTH, OR RELIGIOUS REASONS? IF SO, PLEASE EXPLAIN. WHAT DOES A TYPICAL DAY OF EATING LOOK LIKE FOR YOU? LIST A FEW FOODS/MEALS AND DRINKS YOU USUALLY CONSUME IN THE CORRESPONDING CATEGORIES: BREAKFAST LUNCH DINNER SNACKS WHAT ELSE, IF ANYTHING, WOULD YOU LIKE TO CHANGE ABOUT YOUR NUTRITION? SECTION 6: MENTAL AND EMOTIONAL HEALTH INFORMATION HOW WOULD YOU DESCRIBE YOUR OVERALL MENTAL AND EMOTIONAL HEALTH? HOW DO YOU LIKE TO SUPPORT YOUR MENTAL HEALTH? HOW DO YOU COPE WITH STRESS? USING A SALE OF 1-5 (WHERE 1=NEVER AND 5=ALWAYS), RATE HOW. OFTEN YOU EXPERIENCE EACH OF THE FOLLOWING: ANGER 1 2 3 4 5 EXCITEMENT 1 2 3 4 5 FEAR 1 2 3 4 5 JOY 1 2 3 4 5 LOVE 1 2 3 4 5 SADNESS 1 2 3 4 5 STRESS 1 2 3 4 5 WORRY 1 2 3 4 5 PEACE 1 2 3 4 5 SECTION 7: SPIRITUAL HEALTH INFORMATION WHAT ROLE DOES SPIRITUALITY PLAY IN YOUR LIFE, IF ANY? SECTION 8: LIFESTYLE INFORMATION WHAT ARE THE IMPORTANT RELATIONSHIPS IN YOUR LIFE? IS THERE ANYTHING YOU'D LIKE TO SHARE ABOUT YOUR SOCIAL LIFE? IF SO, PLEASE EXPLAIN. WHO DO YOU LIVE WITH, IF ANYONE? HOW MANY HOURS PER WEEK DO YOU TYPICALLY WORK? WHAT HOBBIES OR RECREATIONAL ACTIVITIES DO YOU ENJOY? WHAT ROLE DOES MOVEMENT, INCLUDING SPORTS, EXERCISE AND PHYSICAL ACTIVITY, PLAY IN YOUR LIFE? SECTION 9: ADDITIONAL COMMENTS PLEASE SHARE ANY ADDITIONAL INFORMATION YOU FEEL RELEVANT TO YOUR HEALTH BELOW. WOOHOO YOU MADE IT!THANK YOU FOR MAKING THE TIME TO COMPLETE THE HEALTH HISTORY. 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