All of your information will remain confidential between you and the Health Coach. PERSONAL INFORMATION Your First and Last Name Your Email How often do you check email? Your mobile phone number Your Age Your Height Your Birthdate Your Place of Birth Your Current Weight Your Weight Six Months Ago Your Weight One Year Ago Would you like your weight to be different? If so, What? SOCIAL INFORMATION Your Relationship Status Where do you currently live? Children Pets Your Occupation Hours of work per week HEALTH INFORMATION 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? How is/was the health of your mother? How is/was the health of your father? What is your ancestry? What blood type are you? How is your sleep? How many hours? Do you wake up at night? Why? Any pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: MEDICAL INFORMATION Do you take any supplements or medications? Please list: Any healers, helpers, or therapies with which you are involved? Please list: What role does sports and exercise play in your life? FOOD INFORMATION What is your food like these days? Your Breakfast Your Lunch Your Dinner Your Snacks Your Liquids Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Do you cook? What percentage of your food is home cooked? Where do you get the rest from? Do you crave sugar, coffee, cigarettes, or have any major addictions? The most important thing I should do to improve my health is: Why did you decide to invest in this program? What was it that inspired you to invest in your health? What’s your mailing address? (You might get some surprises from me from time to time). Please choose which office hours works best for you so we can assign you a cohort. Saturday MorningSaturday AfternoonSaturday EveningSunday MorningSunday AfternoonSunday EveningWeekday Morning Anything else you would like to share?