Health Discovery Form — Hungry Coach

Personal Information
First Name*
Surname*
Refered by
Gender*
- Male
- Female
- Transgender
- Other
Birthdate
Age*
Email*
Phone*
Height*
Current weight*
Desired weight*
When were you last at this weight?*
Your weight 6 months ago*
Your weight 12 months ago*

Social Information
Relationship status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week
How happy are you in your job/career/business?
What do you do to relax and/or have fun? What are you hobbies?
What clubs, groups, or organisations do you belong to?

Health Information
Have you lived or traveled overseas? If so, when and where?*
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you had to take off from work or school in the last year?*
- 0 to 2 days
- 3 to 14 days
- More than 15 days
What are your main health concerns? (Describe in detail, including the severity of the symptoms):*
When did you first experience these concerns?*
How have you dealt with these concerns in the past?*
- Doctors
- Natural therapists
- Self-care
Have you experienced any success with these approaches?
Any serious illnesses/hospitilisations/surgery/injuries?
What role do sports and exercise play in your life?
At what point in your life did you feel your best?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
How would you rate the quality of your sleep on a scale of 1 to 10?
Do you stay awake all day without dozing?
How many hours sleep do you normally get?
What time do you usually go to bed?
Do you fall asleep in less than 30 minutes?
Are you usually asleep between the hours of 2am and 4am?
What time do you usually get up?
Do you wake at night? If so, how often and why?
Any pain, stiffness or swelling? Please explain:
How are your moods in general? Do you experience more anxiety, depression or anger than you would like?
How are your moods in general? Do you experience more anxiety, depression or anger than you would like?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
Bowel Movement Frequency*
- 1-3 times per day
- More than 3 times per day
- Not regularly every day
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Do you have any allergies or sensitivities? Please explain:
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do odors affect you?
Are you or have you been exposed to second-hand smoke?
Do you smoke?
Are you or have you been exposed to second-hand smoke?
Do you have mercury amalgam fillings?
Have you had periods of eating junk food, binge eating or dieting? List any diets that you have been on for a significant amount of time.
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
Men's Health
Do y ou have any concerns or issues with your sexual functioning that you’d like to share with us (libido issues, erectile dysfunction)?
Women's Health
How are/were your menses? Do/did you have PMS? Painful periods: If so, explain.
In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability? If so, explain.
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Have you had any problems with conception or pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here.
Do y ou have any concerns or issues with your sexual functioning that you’d like to share (pain with intercourse, dryness, libido issues)?
Have you reached or are you approaching menopause?

Are you under the care of a medical doctor right now for any medical conditions? Please list:
Medical Information
Please list any natural healers, helpers, therepists with whom you are involved
How often did you take antibiotics in infancy/childhood?
How often have you taken antibiotics as a teen?
How often have you taken antibiotics as an adult? if so, how recently?
Do you take any medications? PLease list:
List all vitamins, minerals, herbs and nutritional supplements you are now taking:

Additional Comments
What are your health goals and aspirations?
Why are the above important to you? Why do you want to achieve that for yourself:
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your body weight and quality of life? Please explain:
Who in you family or on your health care team will be most supportive of you making dietary changes?
Please describe any other information you think would be useful in helping to address your health concern(s):

PLANT-BASED EATING & LIFE COACHING

Health History

Step 1 of 6

Personal Information

Social Information

Health Information

Men's Health

Women's Health

Medical Information

Food information

What foods did you eat often as a child?

What is your food like these days?

Additional Comments