Client Medical History Form

General Patient Information

Please answer every question and be as thorough as possible if the answer is none, please check or type NONE.
Client Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Client Birth Date *

Month Day Year
Client Gender *
Client Height (ft & in) *
Client Weight (lbs.) *
Client E-Mail *
example@example.com
Reason for seeing the health coach: *
Client Medical History
Please list any known drug and/or food allergies *
Have you ever had (Please check all that apply) *

Anemia Asthma Arthritis Cancer Gout Diabetes Emotional Disorder Epilepsy Seizures Fainting Spells Gallstones Heart Disease Heart Attack Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Ulcer Disease Hepatitis Kidney Disease Liver Disease Sleep Apnea Insomnia Fatigue Brain Fog Sugar Cravings Use a C-PAP machine Dyslexia Thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Disorders Lung Disease Emphysema NONE
Other illnesses:
Please list any Operations and Dates of Each *
Please list any Current Medications (to include supplements) *
Parent's Health History
Mother's health history *

Living Deceased
If living health conditions
Other
If deceased, age and cause of death
Father's health history *

Living Deceased
If living health conditions
Other
If deceased, age and cause of death
Healthy & Unhealthy Habits
Exercise (per week) *

Never 1-2 days 3-4 days 5+ days
Eating following a diet *

I have a loose diet I have a strict diet I don't have a diet plan Other
What type of diet (ex. plant based, keto, vegan, etc.)
Alcohol Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Daily Coffee and or Soda Consumption

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Water Consumption

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Do you smoke?

No 0-1 pack/day 1-2 packs/day 2+ packs/day
How determined are you to see the necessary change in your health that you desire?
Include any other comments regarding your Medical History below.
Should be Empty:

General Patient Information

Client Medical History

Parent's Health History

Healthy & Unhealthy Habits