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Meet Flor
What is a Health Coach?
Services
12 Sessions Program
Free Initial Consultation
Group Sessions
Work with Me
Contact
Meet Flor
What is a Health Coach?
Services
12 Sessions Program
Free Initial Consultation
Group Sessions
Work with Me
Contact
Work with Me
Health History
In order for us to make the most out of our first consultation, your Health History will be required. Don't worry if something is not accurate enough, we will have the chance to talk about it during our call
Personal Information
Full Name
(*)
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Email
(*)
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Phone contact
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Sex
(*)
Male
Female
Other
Prefer not to say
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Birthdate
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Month
01
02
03
04
05
06
07
08
09
10
11
12
/
Year
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
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Place of Birth
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Height
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Current weight
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Weight six months ago
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Weight 1 year ago
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Would you like your weight to be different?
Yes
No
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What would your ideal weight be like?
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Social Information
Relationship status
Single
Married
Widowed
Separated
Divorced
In couple
Other
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Where do you currently live and who with?
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Children
Yes
No
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Pets
Yes
No
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Occupation
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Hours of work per week?
Less than 10 hrs
Between 10 and 20 hrs
Between 20 and 40 hrs
More than 40 hrs
Other
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Health Information
Please list your main health concerns
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What is your ancestry?
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is/was the health of your mother?
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How is/was the health of your father?
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What blood type are you?
A+
A-
B+
B-
O+
O-
AB+
AB-
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How is your sleep?
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How many hours do yo sleep?
Less than 5 hours a night
Between 5 and 7 hours a night
Between 7 and 9 hours a night
More than 9 hours a night
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Do you wake up at night?
No
Yes
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Why?
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Any?
Pain
Stiffness
Swelling
Constipation
Diarrhea
Gas
Allergies
Sensitivities
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Please explain
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Are your periods regular?
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How many days is your flow?
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How frequent?
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Painful or symptomatic? Please explain
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Reached or approaching menopause? Please explain
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Birth control history
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Do you experience yeast infections or urinary tract infections? Please explain
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Medical Information
Do you take any supplements or medications? Please list
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Any healers, helpers or therapies with which you are involved? Please list
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What role do sports and exercise play in your life?
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Food Information
What foods did you eat often as a child?
Breakfast
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Lunch
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Dinner
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Snacks
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Liquids
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Will family andor friends be supportive of your desire to make food andor lifestyle changes?
Yes
No
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Do you cook?
Yes
No
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What percentage of your food is home-cooked?
Less than 20%
Between 20 and 50%
Between 50 and 80%
More than 80%
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Where do you get the rest from?
Restaurants
Home Delivery
Supermarket prepacked food
Someone else cooks for me
Other
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I should do to improve my health is
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Additional Comments
Anything else you would like to share?
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Submit
