Non-Binary Health History Form | The New Standard Wellness Coaching

First Name

Last Name

How often fo you check your email?

Phone

Birthday

Age

Height

Place of Birth

Current Weight (in lbs):

Weight 6 months ago:

Weight 1 year ago:

Would you like your weight to be different?

Yes

If so, how?

Relationship Status:

Where do you currently live?

Children:

Pets:

Occupation:

Hours of work per week:

Please list your main health concerns:

Other concerns and/or goals

What point in life did you feel best?

Any serious illnesses/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

How many hours/night?

Any pain, stiffness or swelling?

Constipation, diarrhea or gas?

Allergies or sensitivities? (please explain)