Free Health Coaching Consultation

01

Choose the right history

Who is this form for?

Select the form that best fits the person who will receive coaching.

Adult / GeneralGeneral adult health history Adult MenMen’s health history SeniorSenior health history Female TeenParent / guardian consent required Male TeenParent / guardian consent required ChildCompleted with parent / guardian

02

Personal information

About you

First name * Last name * Email * Phone / WhatsApp * Age Height Date of birth Place of birth

Current weight

Weight six months ago

Weight one year ago

Would you like your weight to be different? If so, what?

Grade

03

Life & context

Your everyday world

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Grandchildren

What is your retirement plan?

What grade are you in?

Do you enjoy school? Please explain.

Do you have a large or small group of friends?

Who is your best friend?

What do you do for fun?

Favourite sport or activity

Fun things you do with family

Favourite things to do when alone

Chores around the house

Why are you completing this health history?

04

Health history

What should Zainab understand before you meet?

This section is for background and coaching context. It is not a diagnostic assessment.

Please list your main health concerns *

Other concerns and/or goals

At what point in your life did you feel best?

Any serious illnesses, hospitalisations or injuries?

How is/was the health of your mother?

How is/was the health of your father?

Ancestry / family origins

Blood type

How is your sleep? How many hours? Do you wake at night?

Any pain, stiffness or swelling?

Constipation, diarrhoea, gas or digestive concerns?

Allergies or sensitivities? Please explain.

What is your energy like?

Do you still feel independent? Please explain.

Are you part of a community? Please explain.

Female teen health

Are your periods regular? How frequent and how many days is your flow?Painful or symptomatic? Please explain.Birth control history, if applicableYeast infections or urinary tract infections, if applicableAny body-image concerns you would like to share?

When is bedtime? When do you wake up?

Do you wake at night or have nightmares?

Bellyaches, headaches or earaches?

Is it hard to see/read or do you get itchy?

Does anything else hurt?

05

Medical & movement context

Current support and activity

Do you take any supplements or medications? Please list.

Any healers, helpers or therapies you are involved with? Please list.

What role do exercise, sports and activity play in your life?

06

Food & lifestyle

Your everyday nourishment

What foods did you eat often as a child? Include typical breakfast, lunch, dinner, snacks and drinks.

What is your food like these days? Include typical breakfast, lunch, dinner, snacks and drinks.

Will family and/or friends support the changes you want to make?

Do you cook? What percentage of your food is home-cooked?

Where does the rest of your food come from?

Do you crave sugar, coffee, cigarettes or have any major addictions?

What do you eat for breakfast?

What do you eat for lunch?

What do you eat for dinner?

What do you eat for snacks?

What do you drink?

What foods do you wish you could eat more often?

What food do you wish you never had to eat again?

What would you like to learn about your body and food?

The most important thing I feel I should do to improve my health is…

Anything else you would like to share?

07

Parent / guardian

Consent for a minor

Required when this health history is for a teen or child.

Parent / guardian name Parent / guardian email Parent / guardian phone

08

Privacy & consent

Submit your history

Your answers contain personal and health-related information. They will be stored privately in the Heal With Zainab WordPress admin and emailed to the site administrator so Zainab can review them before your consultation.

This form is for coaching intake and does not provide a diagnosis, emergency service or medical treatment. For urgent or medical concerns, contact an appropriately qualified healthcare professional.