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Home
About Me
Health Coaching Services
Meri’s Insights
The Circle of Life
The Wahls Protocol®
Home
About Me
Health Coaching Services
Meri’s Insights
The Circle of Life
The Wahls Protocol®
Schedule Meeting
Health History
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Step
1
of 7
PERSONAL INFORMATION
All information will remain confidential between you and the Health Coach
Name:
First
Last
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Email:
How often do you check email?
Once a day
More than once
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Phone: Home:
Work:
Cell:
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Age:
Height:
Birthdate:
Place of Birth:
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Current weight:
Weight six months ago:
One year ago:
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Would you like your weight to be different?
Yes
No
If so, what?
Next
SOCIAL INFORMATION
All information will remain confidential between you and the Health Coach
Relationship status:
Where do you live currently:
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Children:
Pets:
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Occupation:
Hours of work per week:
Next
HEALTH INFORMATION
All information will remain confidential between you and the Health Coach
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?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
How is your bone health if known?
What is your stress level like?
SLEEP HABITS
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How is your sleep?
How many hours a night?
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Do you wake up at night?
Reason
PARENTS HEALTH
How is/was the health of your mother?
How is/was the health of your father?
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WOMEN’S HEALTH (if applicable)
All information will remain confidential between you and the Health Coach
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Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain:
Reached or approaching menopause? Please explain:
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain:
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MEDICAL INFORMATION
All information will remain confidential between you and the Health Coach
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports, exercise play in your life?
What are your hobbies and/or forms of relaxation?
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FOOD INFORMATION
What foods did you eat often as a child?
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Breakfast
Lunch
Dinner
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Snacks
Liquids
FOOD INFORMATION
What is your food intake like these days?
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Breakfast
Lunch
Dinner
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Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
What percentage of your food is home-cooked?
Next
ADDITIONAL COMMENTS
All information will remain confidential between you and the Health Coach
Anything else you would like to share?
Submit
Home
About Me
Health Coaching Services
Meri’s Insights
The Circle of Life
The Wahls Protocol®
Home
About Me
Health Coaching Services
Meri’s Insights
The Circle of Life
The Wahls Protocol®
Schedule Meeting
SCHEDULE MEETING
