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Ideal Balance Health Coaching Intake Form

Personal Information
Name:		Address:
Email::		How often do you check email?
Home Phone:		Work Phone:
Cell Phone:		Age:
Height:		Birthdate:
Place of Birth:		Current Weight:
Weight 6 months ago:		Weight 1 year ago:
Would you like your weight to be different?		If so, what?

Overall Questions
What is not working well for you right now (in your health and/or life overall)?	What are your major obstacles and challenges?

What changes would you like to see as a result of us working together over the next six months?	How will that make a difference in your life?

Social Information:
Relationship Status:		Children?
Occupation:		Hours of work per week:

Health Information:
Please list your main health concerns:	Other concerns?

Any serious illness/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?

Do you sleep well?	How many hours?

Do you wake up at night?	Why do you wake up at night?

Any pain, stiffness or swelling?	Constipation/Diarrhea/Gas?

For Women:
Are your periods regular?	How many days is your flow?

How frequent?	Painful or symptomatic? Please explain:

Birth control history:	Vaginal infections, reproductive concerns?

Medical Information:
Do you take any supplements or medications?	Please List:

Any healers, helpers, pets or therapies with which you are involved?	Please List:

What role do sports and exercise play in your life?

Food Information:

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What's your food like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What percentage of your food is home cooked?
What percentage is not?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?

Additional Comments:

Anything else you would like to share?

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