EHW Health History FormPlease fill this out after our introductory call Name First Name Last Name Date of Birth MM DD YYYY Sex Occupation Phone Country (###) ### #### Email * Preferred Contact Method Phone Call Text Message Email What are your health and wellness goals? Why are they important to you? On a scale of 1-10, how willing are you to improve your health and wellbeing? (1 being not at all, 10 being extremely ready) What about your health and wellness are you most proud of currently? What about your health and wellness is not serving you currently? Please share anything about your health you are comfortable sharing? (E.g. Chronic conditions, allergies, sensitivities...) What have you struggled with in the past related to your overall health and wellness? Do you have any health concerns? (Metabolic health, Digestive health. Reproductive Health, Hormonal health, Immune health, Brain health? Please list any supplements or medicines you take Please describe the health of you immediate family members Weight Height How much water do you drink a day? How many cups of coffee do you have a day? How many hours of sleep do you get a night? What is your weekly alcohol and drug intake? What do you typically eat in a day? (Breakfast, lunch, dinner, snacks, dessert...) What does your movement look like? (Walking, workout classes...) Please share about your past and current relationship to food and exercise Do you struggle with any of the following? (check all that apply?) Following a strict diet Feeling overwhelmed by health and wellness Impressionable by diet culture Lack of sleep Bloating and poor gut health High inflammation Challenges preparing meals Difficulty navigating eating out Lack of variety in meals Overly hungry Lack of appetite Lack of motivation/accountability Thank you for submitting your Health History to me. I look forward to reviewing it with you soon! Best,Emily