Deborah Enos - Speaker, Health Coach and Author

Health History Form

Date:
Full Name:
Address:
City: State: Zip:
Email Address:
Best Phone #:
Age: Birth Date:
Height: Current Weight:
Weight Six Months Ago: One Year Ago:
What is your healthiest weight or size?
When was the last time you were at that weight/size?
Occupation:
Hours of work per week (including commute):
Do you sleep well? How many hours each night?
What time do you go to bed and wake up?
Constipation/Diarrhea?
Explain:
Do you take any supplements or medications? If so, please list:
What role does exercise play in your life?
Are there any foods/drinks that you crave at certain times of the day?
If so, when?
What % of your meals are home cooked?
What time of day/meals are you more likely to eat out?
What are your top three health goals or priorities?
1.
2.
3.
How is your mother's health?
How is your father's health?

What foods did you often each as a child?

Breakfast Snacks	Lunch Liquids	Dinner

What about one year ago?

Breakfast Snacks	Lunch Liquids	Dinner

What foods are you currently eating?

Breakfast Snacks	Lunch Liquids	Dinner