Master Certified Health Coach Health Intake Form Health Intake Form Basic Information Name * First Last * Last Email * Phone * Health Profile Why are you seeking help now? What goals would you like to set for your health? (i.e. are you looking for a "quick fix" or a lifestyle change?) What all have you tried that has NOT worked for you? Please list any unusual stress factors you're facing List any known allergies to food or medicine What medical diagnosis have you received? List all current prescription medication, and the underlying condition Health Habits Rate your current health habits, with 10 being the absolute best and 0 being totally nonexistent... Water intake (Ideal: body weight / 2 = total "ounces" daily) 1 2 3 4 5 6 7 8 9 10 Sleep quality and time (Ideal: 8 hrs, uninterrupted, nightly) 1 2 3 4 5 6 7 8 9 10 Exercise and movement (minimum = 30 minutes daily) 1 2 3 4 5 6 7 8 9 10 Personal gratitude practice (reading, using affirmations, meditation and prayer, positive community) 1 2 3 4 5 6 7 8 9 10 Fruits & Vegetables intake (minimum = a variety of at least 7 servings the size of your fist a day) 1 2 3 4 5 6 7 8 9 10 Food quality (Ideal: Mostly organic, mostly raw) 1 2 3 4 5 6 7 8 9 10 What times of day to you typically eat meals? Do you frequently snack in between meals? YesNo Do you eat food products with dairy? YesNo If yes, please list... Do you eat food products with wheat / gluten? YesNo If yes, please list... Do you experience sugar cravings? YesNo If yes, please list... Do you eat food products with food dyes? YesNo If yes, please list... Do you take vitamins or other supplements? YesNo If yes, please list... Do you like to shop for food? YesNo Do you like to prepare meals? YesNo Are you interested in learning to shop differently and prepare meals that will support your health goals? YesNo Where are you on the motivation scale below? 50 I NEED ACCOUNTABILITYI'M SELF-MOTIVATED To be successful, who do you need support from? Final Thoughts Please share any other information you feel is relevant to your health and health goals * If you are human, leave this field blank. Send Health Intake Information
