Health Coach Personal InformationFull Name *Date of Birth *AgeSex Assigned at BirthGender IdentityPreferred PronounsStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweEmail Address *PhoneOccupationPreferred Contact MethodPhoneTextEmailMailEmergency Contact Name *RelationshipEmergency Contact Phone *HEALTH AND WELLNESS GOALSTell us more about your current goals and what motivates you to achieve them.What are your health and wellness goals? Why are they important to you?PERSONAL HEALTH AND FAMILY HISTORYShare details about your health story, current conditions, family history and access to healthcare.What’s the most important thing you’d like to share about your health story?Please list any supplements or medications you takeMedical diagnoses or conditionsHistory of serious illnesses, hospitalizations, injuries, or surgeriesHave you experienced any barriers or challenges to accessing healthcare?Primary care providerOther physicians or specialistsPractitioners, therapists, healers, etc.Family HistoryTell us more about your family's health background and anything from your childhood that may be relevant.Describe the health of your motherDescribe the health of your fatherIs there anything from your childhood pertaining to your health you’d like to share?Do you have any other notable family or personal health information you’d like to share?Current WeightHeightHow many hours do you sleep per night on average?How would you describe your quality of sleep?How is your energy level most days? (1–5 scale)Energy level12345Physical Health InformationPlease share any physical symptoms or diagnosed conditions you experience regularly.Do you experience any pain, stiffness, or swelling on a regular basis?Do you have any of the following concerns?⤷ Blood Sugar Imbalances⤷ Elevated Blood Pressure⤷ Elevated Cholesterol⤷ Elevated Triglycerides⤷ OtherIf Other, please specifyHow many bowel movements do you have on average per day?Reproductive, Digestive & Hormonal HealthPlease select all concerns that apply to your health.Reproductive Health ConcernsInfertilityIrregular Menstrual CycleLow LibidoOtherIf Other (Reproductive), please specifyDigestive Health ConcernsConstipationBloatingDiarrheaNauseaStomach PainGasOtherIf Other (Digestive), please specifyHormonal Health ConcernsSigns or Symptoms of Hormonal ImbalanceToxin ExposureThyroid ConditionIf Other (Hormonal), please specifyImmune & Brain HealthTell us if you have any immune-related or brain-related concerns.Immune Health ConcernsAutoimmune ConditionsLow Vitamin D LevelFrequent Illness or InfectionAllergies and SensitivitiesOtherIf Allergies or Other (Immune), please specifyBrain Health ConcernsBrain FogDifficulty ConcentratingForgetfulnessOtherIf Other (Brain), please specifyNutrition & Food RelationshipTell us more about your eating habits, food history and nutrition concerns.What foods did you grow up eating?How would you describe your past relationship or history with food?Do you have any food allergies or intolerances? If so, please listDo you follow a specific eating practice (e.g., vegan, keto, kosher)?What does a typical day of eating look like?Breakfast:Lunch:Dinner:Snacks:Do any of the following apply to you? (Challenges with food access etc.)Challenges with Preparing MealsPoor AppetiteDifficulties Chewing or SwallowingChallenges with Access to FoodDo you regularly use any of the following?AlcoholTobacco ProductsOther SubstancesIf Other Substances, please specifyDescribe your current relationship with foodWhat would you like to change about your nutrition?Mental, Emotional, Spiritual & LifestyleLet us know more about your mindset, stress levels, and daily lifestyle habits.How would you describe your overall mental and emotional health?Anger 1-5Excitement 1-5Fear 1-5Joy 1-5Love 1-5Sadness 1-5Stress 1-5Worry 1-5How do you like to support your mental health?How do you cope with stress?Spiritual HealthWhat role does spirituality play in your life?Lifestyle & Daily LivingWhat are the important relationships in your life?Is there anything you’d like to share about your social life?What role does movement, including sports or activity, play in your life?Who do you live with, if anyone?How many hours per week do you typically work?What hobbies or recreational activities do you enjoy?Is there anything else you’d like to share?Submit message
