Adult Health History

Please complete the following questions carefully. This information will help us to build a specialized nutritional program, personally designed for you.
All information listed will remain confidential between client and health coach.

Personal Information

Health Challenge(s)
Other Information
Medications
Cravings
Smoking
Surgeries
Scars
Stress
Dental Work

Health Overview

For the following questions, please check the phrases that apply to you:
Sleep
Digestion
Urination
Bowels

How are you bowel eliminations?

Women Only
Menstrual Cycle
Exercise
Sunlight
Eyewear
Electromagnetic Exposure
How many hours do you spend daily with the following devices:
Personal Care Products
Appliances
Cookware
Shower filter
Pets

Food Choices

Please check each type of food that you eat often (once a week or more):

Food Habits

Eating Out
Home Meals
Meal Habits
MSG
Water

Typical Diet

Please fill out your typical diet for the last few weeks. Please be as detailed as possible. (For example, instead of writing "chicken", identify what brand and how it was prepared "baked organic chicken". Instead of writing "salad", identify what it was made of, such as "salad made with organic baby green lettuce, commercial cherry tomatoes and PRL olive oil".) PLEASE BE HONEST!

Bedroom/Sleep Considerations

Bedding Materials
Mattress
Head Direction
Darkness
Electronic Appliances
Clock Radio
Windows
Alarm
EMF Exposure

Previous Treatments

Electrical Devices Worn on Body

EMF Exposure

Toxic Body Exposure

Vaccinations

Personal Health Goals