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GF Sourdough Lab
Recipe Blog
Events
Store
About
Coaching
Confidential Health History
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
How often do you check email?
*
Phone
Work
(###)
###
####
Phone
Home
(###)
###
####
Phone
Cell
(###)
###
####
Age
*
Height
*
Date of birth
*
MM
DD
YYYY
Place of Birth
*
Current Weight
*
Weight six months ago
*
Weight one year ago
*
Would you like your weight to be different?
*
If so, what?
Relationship status:
*
Children
*
Pets
*
Occupation
*
Hours of work per week
*
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?
*
Do you sleep well? How many hours? Do you wake up at night? Why?
*
Any pain, stiffness or swelling?
*
Constipation/Diarrhea/Gas? Please explain:
*
Allergies or sensitivities? Please explain:
*
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?
*
What foods did you eat often as a child?
*
List breakfast, lunch, dinner, snacks, liquids
What’s your food like these days?
*
List breakfast, lunch, dinner, snacks, liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
*
What percentage of your food is home cooked?
*
Do you cook?
*
Where do you get the rest from?
*
Do you crave sugar, coffee, cigarettes, or have any major addictions?
*
The most important thing I should change about my diet to improve my health is:
*
How ready and willing are you to make changes in your life?
*
Anything else you want to share?
*
For women only
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:
Thank you!
