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Be Better Health Coach 2023 Designed by Beach Web Solutions

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Pre Coaching Questionier

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Health History Form

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Step 1 of 6

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Personal Information

Name*

First Last

Date of Birth*

Month

Day

Year

Age

Sex Assigned at Birth*

Male

Female

Occupation

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Contact Method

Phone

Text

Email

Mail

Emergency Contact Name

Relationship

Phone

Health And Wellness Goals*

What are your health and wellness goals? Why are they important to you?

Personal Health and Family History

Whats the most important thing you'd like to share about your health story?

Do you have any of the Following?

Primary Care Provider

Other Physicians or Specialists

Practioners, Therapists, Healers, etc

Do you have any of the Following?

Primary Care Provider

Other Physicians or Specialists

Practioners, Therapists, Healers, etc.

Pleast list any supplements or medications you take:

Have you experienced any barriers or challenges to accessing health care?

Medical diagnoses or conditions:

History of serious illnesses, hospitalizations, injuries, or surgeries:

Family History

Describe the health of your:

Mother:

Father:

Is 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?

Physical Health Information

Current Weight:

Height:

How 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

2

3

4

5

Do you experience any pain, stiffness, or swelling on a regualr basis? If so, please explain:

Metabolic Health

Blood Sugar Imbalances

Elevated Cholesterol

Elevated Blood Pressure

Elevated Triglycerides

Other

Other:

Digestive Health

Bloating

Constipation

Diarrhea

Gas

Nausea

Stomach Pain

Other

Other:

Reproductive Health

Infertility

Irregular Menstrual Cycle

Low Libido

Other

Other:

Hormonal Health

Thyroid Condition

Toxin Exposure

Signs or Symtoms of Hormonal Imbalance

Signs/Symtoms of Hormonal Imbalance (please list)

Immune Health

Autoimmune Conditions

Frequent Illness or Infection

Low Vitamin D Level

Allergies and Sensitivities (please list)

Other

Other:

Allergies and Sensitivities

Brain Health

Brain Fog

Difficulty Concentrating

Forgetfullness

Other

Other:

Nutrition Information

What foods did you grow up eating?

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 with food:

Do you have any food allergies or 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

Other:

Do you follow a specific eating approach/practice for personal, health or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:

Typical daily diet

What does a typlical 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, if anything, would you like to change about your nutrition?

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?

Emotions Check in

Using a 1-5 scale (where 1 = never and 5 = always), rate how often you eperience each of the following:

Anger

Excitement

Fear

Joy

Love

Sadness

Stress

Worry

Spiritual Health Information

What rolle does spirituality play in your life, if any?

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 hobbbies or recreational activities do you enjoy?

What role does movement, including sports, exercise, and physical activity, play in your life?

Additional Comments

Is there anything else you'd like to share?

Consent*

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Name

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