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FREE Health History
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Michelle Arington, RYT, C-IAYT, INHC
Congratulations for deciding to reclaim your health
and taking this next step forward!
Not only as a certified health coach with over 8 years of experience empowering my clients achieve their personal health, fitness, and stress management goals, but also as a busy mother, wife, teacher and entrepreneur, I know how challenging it can be to put yourself first.
I've been there. You're not alone.
To commit to yourself and take the first step toward balance,
please complete and submit this form.
I am looking forward to meeting with you and discussing the possibilities!
All information shared in this health history will remain private and confidential.
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Place of Birth
Hours per week
8 - 10 Very satisfied
0-2 Can't wait to quit!
Top 3 Main Health Concerns
Other Concerns & Goals
When in life did you feel your best?
How is the health of your mother/father?
What is your ancestry?
Daily stress level
0 - 2 Totally chill.
3 - 5 Just enough to keep me moving.
6 - 8 Always stressed, can't relax.
9 - 10 Panic-mode/attacks
Lack of sleep
Health/illness of family member
Recent death of a loved one
Recent life change
Hours of sleep
8 - 10 I sleep great!
6 - 7 Is enough for me!
5 - 6 Could really use more.
2 - 4 Sleep? What's sleep?
Do you wake up at night?
Do you feel rested?
Do you have a meditation or mindfulness practice?
Would like guidance on how to begin a practice for stress management?
Current care providers
Typical diet as a child/teen
Typical diet now
Do you take supplements?
Do you take OTC or prescription drugs?
If yes, please list
If yes, please list
Percentage of home-cooked meals
80 - 100 %
20% or less
What do you crave?
Do you cook?
Yes, I love to cook!
Yes, but I don't really enjoy it.
My partner does all the cooking.
Only when I have to.
Never. I don't have time.
Never. I'm a terrible cook
Never. I hate to cook.
How much water do you drink?
1 - 2 glasses
3 - 4 glasses
5 - 6 glasses
7 - 8 glasses
Never, I hate to drink water.
Number of times per week/duration of exercise
Have you been advised by a health practitioner to avoid physical exercise?
Do you feel you would benefit from personal fitness training that suits your needs and goals?
I don't know
Favorite physcial activities
Any muscle or joint pain?
Are you interested in learning about Yamuna®, Reiki, or Yoga Therapy for pain management?
If yes, select all that apply
What do you believe are your biggest obstacles to achieving your desired health and fitness goals?
What do you think should be your first step towards achieving your desired goals?
How did you hear about this free opportunity?
This Health History consultation is not intended to diagnose or treat any disease, illness or chronic condition or to be used as a substitute for medical advice. Please consult with your advising physician or mental health provider before starting any alternative treatment for a medical or mental/emotional condition.
Do you acknowledge that you read and understand the above statement?
Yes, I read and understand
* Nourish * Renew * Balance * Transform *
Michelle Arington, RYT, C-IAYT, CHC
MindBody Health & Wellness Coach
Core Integrity Yoga & Fitness
Yamuna®, Yoga Warriors™, NASM CPT, Silver Sneakers®, Ageless Grace™
The information provided on this website is for educational purposes only.
Please consult a certified medical professional for appropriate medical diagnosis or treatment of disease.