Health History Submission Form Please enable JavaScript in your browser to complete this form.Name *FirstLastGenderMaleFemaleDate of birthAge Selected Value: 18 Height (cm or feet/inches specify) *Relationship statusSingleIn a relationshipMarried Do you have children?YesNoNot currently, but trying / want in the futureDo you have any pets?YesNoWhat is your occupation? How many hours do you work every week?Part time (Less than 30 hours)Full time (35-40 hours)Overtime (40+ hours)Way Too Much (60+ hours)How active are you every week?Sedentary (office job)Light Exercise (1-2 days/week)Moderate Exercise (3-5 days/week)Heavy Exercise (6-7 days/week)Hyper-Active (workout 2x/day multiple days in week)Current Weight / Weight Six Months Ago / Weight One Year Ago (kg or lbs specify) *Would you like your weight to be different? If so, how? *How much sleep do you get usually? *Less than 7 hours7 – 9 hours More than 9 hoursRate the quality of that sleep here. (1 = worst, 10 = best) Selected Value: 1 Do you wake up in the middle of the night? If so, why? *Do you have any health-related goal(s) in mind? *(This is a place for you to describe what you want to accomplish working with me. For example, you may want to lose weight in order to run a marathon, compete in a triathlon, or fit into that wedding dress that you’ve always wanted to wear.)What are your main health concerns? *(Here please tell me if you have any health conditions that I should be aware of i.e. diabetes, celiac disease, terminal cancer, etc. Lay it all out for me.) Do you crave caffeine, sugar, or cigarettes? Do you have any other major addictions? *What is the most important thing you should change about your lifestyle to improve your health? *At what point in your life did you feel your best? Why?On a scale of 1-10 how committed are you to becoming healthier? Selected Value: 0 On a scale of 1-10 how willing are you to invest in making a change in your life? Selected Value: 0 Is there anything else I should know about you or your situation before moving forward?What is the BEST email to follow up with you about your goals? *Submit
