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| Get Acquainted Health Form
Ideal Balance Health Coaching Intake Form
How often do you check email?
Place of Birth:
Weight 6 months ago:
Weight 1 year ago:
Would you like your weight to be different?
If so, what?
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
How will that make a difference in your life?
Hours of work per week:
Please list your main health 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?
Are your periods regular?
How many days is your flow?
Painful or symptomatic? Please explain:
Birth control history:
Vaginal infections, reproductive concerns?
Do you take any supplements or
Any healers, helpers, pets or therapies
with which you are involved?
What role do sports and exercise play in
What foods did you eat often as a child?
What's your food like these days?
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?
Anything else you would like to share?
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