Health Form Health Form Get ready to live a Smart Life! Please complete this form at least 24 hours prior to your requested appointment. Be sure to fill it out completely. The more specific you get about where you’re at and where you want to be, the more we can achieve together. Your appointment will be confirmed after you hit the submit button below. Personal InformationPlease fill in all form fields. All of your information will remain confidential between you and Smart Life Health Coaching.Name* First Last Email* I check my email...--HourlyDailyWeeklyMonthlyRarelyBest phone I can be reached at*--MobileHomeOfficeEnter phone number*Secondary phone I can be reached at (Optional)--MobileHomeOfficeEnter phone numberBirthdate Month Day Year Gender*--MaleFemaleHeight*--6'6" and above6'5"6'4"6'3"6'2"6'1"6'0"5'11"5'10"5'9"5'8"5'7"5'6"5'5"5'4"5'3"5'2"5'1"5'0"4'11"4'10"4'9"4'8"4'7"4'6" and belowPlace of birth:AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCurrent weight* Weight six months ago Weight one year ago Would you like your weight to be different?*--YesNoYour prefered weight?* Social InformationRelationship Status--SingleMarriedDivorcedWidowedWhere do you currently live? Children--YesNoList your childrens with agesPets--YesNoOccupation Hours of work per week Health InformationPlease list your main health concerns.Other concerns and/or goals?At what point in your life did you feel best?Any serious illnesses/hospitalizations/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?--OABABHow is your sleep?How many hours of sleep do you get each night?--4 hours or less5 hours6 hours7 hours8 hours9 hours10 hours or moreDo you wake up at night?--YesNoWhat are the reasons you wake up at night?Any pain, stiffness, or swelling?--YesNoPlease describeAny Constipation, Diarrhea or Gas?--YesNoPlease describeAllergies or sensitivities?--YesNoPlease specifyWomen's HealthAre your periods regular?--YesNoHow many days is your flow? How frequent? Painful or symptomatic?--YesNoPlease explainReached approaching menopause?--YesNoPlease explainBirth control historyDo you experience yeast infections or urinary tract infections?--YesNoPlease explainMedical InformationDo you take any supplements or medications?--YesNoPlease listAny healers, helpers, or therapies with which you are involved?--YesNoPlease listWhat role do sports and exercise play in your life?Food InformationWhat is your food like these days?BreakfastLunchDinnerSnacksLiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes?--YesNoDo you cook?--YesNoWhat percentage of your food is home-cooked? Where do you get the rest from? Do you crave sugar, coffee, cigarettes, or have any major addictions?--YesNoPlease describeThe most important thing I should do to improve my health isAdditional CommentsAnything else you would like to share? Δ If you have problems submitting the form, you can download it HERE. Please Save it to your computer and email it to the address on the form once complete.