Health Coach Client Intake Form
Personal Details
Full Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Company Name
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone No.
Please enter a valid phone number.
Best time to call
Hour Minutes
AM
PM
AM/PM Option
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Current Health Statistics
Blood Type
Weight (kg)
Height (cm)
Body Mass Index (BMI)
Appointment
Preferred Day/Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Time
Hour Minutes
AM
PM
AM/PM Option
Schedule of the first appointment
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Are you currently seeing a therapist or coach?
Yes
No
Is this the first time you hired a health coach or have you been with one before?
Yes
No
What is your purpose in getting a health coach?
What are you expecting to get from the heath coaching sessions?
What are you goals and ambitions in life?
Please fill up the table below:
Yes
No
Occasional
Remarks/Notes
Difficulty of sleeping
1
2
3
Smoking
4
5
6
Drinking alcohol
7
8
9
Pregnant (Female)
10
11
12
Daily exercise
13
14
15
Surgical History
16
17
18
Drinking soda
19
20
21
Drinking caffeinated products
22
23
24
Sexually active
25
26
27
Do you have any allergies? If yes, please list them below:
Are you currently taking any medications? If yes, please identify the medication name and purpose:
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Please check below if you have any of the current health conditions:
Present
Not Present
Remarks
Gastrointestinal
28
29
Respiratory
30
31
Cardiovascular
32
33
Neurological
34
35
Dermatological
36
37
Musculoskeletal
38
39
Urinary
40
41
Reproductive
42
43
Metabolic
44
45
Endocrine
46
47
What are the things or ways that you do to manage stress?
What relaxation techniques do you do?
What are the things that make you happy?
What are the things that doesn't make you happy?
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Terms and Conditions
I confirmed that all information in this form is accurate and try to the best of my knowledge.
I confirmed that I have read the contents of this form including these terms and agreement.
I understand that this clinic or health facility will protect all the information in this form and will keep it confidential.
I understand that this clinic/facility accepts cash, check, and credit cards for payment methods.
I understand that this procedure is not considered professional advice. It is recommended to seek professional advice from professionals like lawyers, physicians, spiritual, and financial.
I confirmed that I have the right to terminate this care at any time.
I released this clinic or facility from any liabilities like injuries, accidents, or damage that might happen during the procedure.
I understand that this procedure doesn't guarantee specific results or outcomes.
Patient Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: