Personal Information

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

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* 1. First Name:

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* 2. Last Name:

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* 3. Email:

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* 4. How often do you check email?

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* 5. Phone (Home):

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* 6. Phone (Mobile):

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* 7. Age:

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* 8. Height:

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* 9. Date of Birth:

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* 10. Place of Birth:

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* 11. Current weight:

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* 12. Weight six months ago:

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* 13. Weight one year ago:

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* 14. Would you like your weight to be different?

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* 15. If so, what?

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* 16. Why did you come for a Health History?

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