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Health History Questionnaire
I'm looking forward to getting to know you better and working with you. Please fill out all the questions as completely as possible prior to our initial session. ~Karla
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Email
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Your email
Full Name
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Your answer
Email Address
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Your answer
Location/Timezone (Example: Texas, CST/MST or New York, USA/EST)
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Your answer
Phone Number
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Your answer
Occupation
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Your answer
Family/Living Situation? (Live alone? Partner? Married? Have kids? How many? Pets? Names of pets.)
Your answer
Height
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Your answer
Weight
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Your answer
List your main concerns or goals which have prompted you to seek out health coaching.
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Your answer
Do you experience any of the following?
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Acne-Face
Acne-Body
Exzcema
Psoriasis
Lack of Sleep
Strange/Unexplained Rash
Joint Pain/Stiffness
Dandruff
Headaches/Migraines
Weak nails that break or tear easily
Bloating (frequently or more than once a week)
Gas (frequently or more than once a week)
Diarrhea
Constipation (going #2 less than once a day)
Hard to pass stool
Pellet of pebble like stool
Phglem in back of throat
Catch colds, flu, viruses, easily/frequently (more than once a year)
PMS- breast tenderness, bloating, cramps, mood swings, etc. around menstrual cycle
Period issues (too long, too short, not coming on time, very heavy, etc,)
Had Mono
Taken antibiotics in the last 6 months
Taken antibiotics in the last year
Auto-immune Disease
Gastrointestinal Issue/Disease
Cardiovascular Disease or Condition
Diagnosis of Other Diseases or Conditions
Required
If you checked the box for any of the starred items above, please elaborate. (Write N/A if not applicable). Or, if you struggle with something else you can share the details here.
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Your answer
If you are desiring weight loss, what is your desired weight?
Your answer
Please describe your relationship with food and your body as it is right now. What exactly are you struggling with?
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Your answer
What is your biggest obstacle(s) in reaching those goals? What is getting in your way?
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Your answer
How is this issue affecting you in your life? Be specific. How does it affect your relationships, confidence, career, etc?
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Your answer
What do you need the most help with? Check all that apply.
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Acne
Weight Loss
Psoriasis
Eczema
Lack of Energy
Education on What to Eat
How to Cook
Confidence
Body Image
Emotional Eating
Binge Eating
Eating at Night
Anxiety/Stress
Sugar Addiction
Coffee Addiction
Better Sleep
Required
What have you done in the past to lose weight, or address the above issues?
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Your answer
Briefly describe your current daily eating habits. Do you follow a certain style of eating (dairy-free, gluten0free, paleo, vegan, etc.). Do you avoid certain foods? Which foods do you eat a lot of?
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Your answer
If you take any supplements or medications on the regular, please list them here.
Your answer
Check all of the factors that apply to your current lifestyle and eating habits.
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Fast Eater
Erratic Eating Problem
Eat too Much
Late Night Eating
Dislike Healthy Food
Time Constraints
Eat more than 50% meals away from home
Travel Frequently
Non-availability of Healthy Foods
Do not plan meals or menus
Reliance on Convenience Items
Poor Snack Choices
Significant other or family members don't like healthy foods
Significant other or family members have special dietary needs or food preferences
Love to Eat
Eat because I have to
Have a negative relationship with food
Struggle with eating issues
Emotional eater (eat when sad, lonely, depressed, bored)
Eat too much under stress
Eat too little under stress
Don't care to cook
Eating in the middle of the night
Confused about nutrition advice
Sugar Cravings
Salty Cravings
Fatty/Greasy Carvings
Required
How did you find out about my program?
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Instagram
Google
Friend
Facebook
Youtube
Other:
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Send me a copy of my responses.
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