Health History First Name (required) Last Name (required) Age Marital Status SingleMarriedDivorcedWidowed Number of Children Please list health issues Share an example of your daily diet How much of your daily diet is cooked at home? Do you currently exercise? YesNo If so, what do you like to do and how often? What is your top health goal right now? What is your top life goal right now? How do you hope health coaching will assist you? How motivated are you to do homework? Not at allSomewhatVery Do you consider yourself to be healthy: Mentally YesNo EmotionallyYesNo Physically YesNo SpirituallyYesNo Socially YesNo
