Health Discovery Form Step 1 of 6 16% Personal InformationFirst Name*Last name*Date Date Format: MM slash DD slash YYYY Email* Phone*Time zone*Age*Height*Current Weight*Would you like your weight to be different? If so, what?*Social InformationRelationship StatusSingleMarriedDivorcedWidowedUnder 18Where do you currently live?*OccupationJob SatisfactionI like my job.I like parts of my job.I wish I had a different job.I wish I had a different career.General Relationships:Most of my relationships with others are good.I often have conflicts with other people.Some of my relationships need improvement.Kids? Pets? 🙂ChildhoodHappyAverageChallengingPersonality (click all that apply)*Type A: In charge and in controlType B: Outgoing and energeticType C: Detailed and logicalType D: Easy going and hard workerIntrovertExtrovert Health InformationPlease list your main health concerns:*Number of days you work out each week:*At what point in your life did you feel best?*Any serious illnesses/hospitalizations/injuries?*How is your sleep?*Hour many hours on average do you sleep at night?*Less than 44 - 56 - 78+Sleep habits (circle all that apply in dropdown box):*Asleep between 10pm-11After 11pmAfter 12pmI need an alarm clockI fall asleep when I watch TV or readI wake up feeling unrestedHow do you deal with stress? Click all that apply.*Over eatSmokeDrink alcoholExerciseJournal feelingsTalk about stress with friend/otherWatch TVGet irritatedPrayRestless legs? Cramping? (not pms)*Any pain, stiffness or swelling?*Constipation, diarrhea or gas?*This means, are you going #2 once or twice a day?Allergies or sensitivies? Please explain:*Smoking:*Never smokedQuit over 5 years agoQuit less than 5 years agoQuit less than 1 year agoCurrently smokeCurrently smoke and WANT to quit Women's HealthAre your periods regular? ( or n/a)*Do you have PMS, painful periods or other symptons? Other details (or n/a):*Birth control history (or n/a):*General Health ConcernsDo you have concerns with any of the following, select all that apply:*Yeast infections / Urinary tract infectionsAcneHormonal issuesMood swingsDepression / AnxietyDry skinHair loseCholesterolEye healthBlood pressureErectile issuesInsomiaNoneGot a habit you need to kick?* Do you take supplements or medications? Please list (or n/a):*Are you involved in holistic therapies (chiro, acupuncture, therapist, etc) (or n/a):* Food / Dietary InformationHow well do you eat?*Do you cook and percentage of food cooked at home:*Do you crave sugar, coffee, cigarettes or other things?* Conclusion and finishing upHow are you doing mentally? You ok?*What is the most important thing you can do to improve your health?*Do you have health related goals?Anything else you would like to share?EmailThis field is for validation purposes and should be left unchanged. Δ 2016-04-06 Coach BK
