Health History Intake Form

Health History Intake Form

All of your information will remain confidential between you and the Health Coach.
Personal Information
Name*

First NameLast Name
Phone Number*
Email*
How often do you check email?*
Age:*
Date of Birth*

DayMonthYear
Date
Height*
Current Weight*
Weight six months and one year ago*
Would you like your weight to be different? If so, what?

GP Details
Family doctors name*
Phone Number*
Do I have permission to contact your doctor if it becomes necessary to do so?*

YesNo

Health History Information
Please list your main health concerns. With each concern please state: When it started? What aggravates or relieves it? Level of progression?*
List in the order of priority
Any serious illnesses, hospitalisations, injuries?*
Where you breast fed as a baby? If so for how long?
Do you currently (or in the past 6 months) take any medications (incl supplements) ? Please list & explain *
Allergies or sensitivities? Please explain*
How is your sleep hygiene? How many hours? Do you wake up at night? Why?*
Any pain, stiffness or swelling?*
How would you describe your digestive health? Please provide details about any regular symptoms or concerns. Constipation, gas, diarrhoea, abdominal pain, bloating, IBS etc *
Do you experience any symptoms or signs that may indicate nervous system issues, such as headaches, visual disturbances, pins and needles, weakness, numbness, or other relevant symptoms? Please provide details if applicable.*
Do you experience any symptoms or signs that could indicate endocrine system issues, such as unexplained weight loss or gain, excessive thirst, changes in appetite, or other relevant symptoms? Please provide details if applicable.*

Women's Health
Are your menstrual cycles generally regular in terms of timing?
On average, how many days does your menstrual flow usually last?
Do you experience any discomfort, pain, or other symptoms associated with your menstrual cycle?
Do you use any app to track your cycle? (oura ring, natural cycles, apple health etc)
Birth control history
Do you have any current concerns or questions regarding your fertility?
Reached or approaching menopause? If so, what symptoms (if any) are you experiencing?
Any significant pregnancy or childbirth history?
Is there anything related to your sexual health that you are currently concerned about or would like to discuss?
Do you experience any yeast infections or urinary tract infections? Please explain

Mens Health
Do you have any current concerns or questions regarding your fertility?
Do you experience any challenges with achieving or maintaining an erection?
Is there anything related to your sexual health that you are currently concerned about or would like to discuss?

General Health Information
Do you suffer from cold sores? If so, how often?
Do you bruise easily/wounds heal easily?
Do you suffer from asthma or difficulty breathing?
Do you ever suffer from chest pain?
Do you experience any difficulties with urination, such as incontinence or other related problems?
Have you had your blood pressure checked in the last 6 months? If yes, please provide the most recent reading.
Do you experience any of the following symptoms related to muscles or joints? Please check all that apply:

MuscularJoint painBack painCrampsSpasmsOther
Do you currently have any concerns or conditions related to your skin health? Please provide details if applicable.

Relationships, Family Health History and Stress
Could you please share some information about the most significant relationships you've had in your life, whether they are current or within the past five years?
Support network / Family / Friends / Colleagues / Partner etc

How would you rate your current stress levels?

	0	1	2	3	4	5	6

0 is No stress, 6 is Suffering very badly with stress

Health Goals
What do you believe is the most crucial step you could take to enhance your overall health?
What are your current health goals or objectives?
At what point in your life did you feel your best?

Goals
Please describe any steps you have taken in the past to address your conditions. What strategies or approaches seemed to work well for you, and were there any that did not yield the desired results?
What are your goals for the next 30 days and the next 90 days in terms of your health and well-being?
How would you feel if you got these results?
What do you perceive as the main obstacles, challenges, or struggles that are currently hindering your progress toward achieving the results you desire?
Anything else you would like to share?
Should be Empty:

Personal Information