Please fill out this form prior to our scheduled discussion so that I have as much information to help formulate a personalized plan for you. All of your information will remain confidential between you and me, your Health Coach. – Kassy Web Site Fields marked with an * are required. Personal Information First & Last Name * Email * Phone * Age Height Birthdate Place of Birth Current weight Weight six months ago & 1 year ago? Would you like your weight to be different? If so, what? Social Information Relationship Status Single Married Divorced Widowed Where do you currently live? Children? Yes No Pets? Yes No Occupation Hours of work per week? Do you like your job? (1=not at all) (5=it's ok) (10=it's my dream job) Health Information Please list your main health concerns: At what point in your life did you feel best? Any serious illnesses/hospitalizations/injuries? How is the health of your mother? How is the health of your father? What is your ancestry? What blood type are you? How is your sleep? How many hours do you sleep? Do you wake up at night? If yes, why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? Allergies or sensitive? Please explain. Are your periods regular? How often? How many days if your flow? Painful or symptomatic? Please explain. Reached or approaching menopause? Please explain. Birth control history. Have you ever been pregnant? How many live births? Do you experience yeast infections or urinary tract infections? Please explain. Medical Information Do you take any supplements or medications? Please list. Any healers, helpers or therapies with which you are involved? Please list. Did you play sports as a child? Which sport? Did you ever have any injuries, as a result? Are you currently involved in a sport? Explain in as much detail as possible: Food Information What foods did you eat often as a child? As a Child - Typical breakfast, lunch, dinner, snacks & beverages: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Yes No Maybe Not Sure Do you cook? Yes No Sometimes What percentage of your food is home-cooked? 1 Where do you get the rest from? Do you crave sugar, coffee, cigarettes or have any major addictions? The most important thing I should do to improve my health is? What is your food like these days? Now - Typical breakfast, lunch, dinner, snacks & beverages:t How much water do you drink daily? Do you drink alcohol/caffeine? How much per day?: What are your goals 3 months from now? One year from now? Additional Comments Anything else you would like to share?