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Healthy Lifestyle Coaching With Holly
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Health History Form
First name
Last name
Phone
Email
Birthday
Month
Month
Day
Year
What is your occupation?
How many hours do you work a week?
What is your current weight?
Would you like your weight to be different?
What is your relationship status?
Do you have children
Do you cook?
What might a typical day of eating look like for you?
How many hours do you sleep a night?
Please list any pain, stiffness, or swelling you have.
Please list any allergies or sensitivities.
If you are biologically female, please select your current hormonal stage of life.
Please explain the role exercise and/or movement play in your life.
At what point in your life did you feel your best?
Please list your main health concerns.
Please list any other concerns and/or goals.
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