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Meet Margie
Testimonials
Programs
Happy Bones, Happy Life™ Program
Happy Me, Happy Life Program
Beat the Belly Fat, Bloating, Bone Loss and the Blues
One-on-One Coaching
Podcast
My Book
Blog
Recipes
Desserts and Snacks
Grains
Main Courses
Salads
Shakes and Smoothies
Sides
Soups
Contact
Health Form
Health Form
Women's Health History
All of your information will remain confidential between you and the Health Coach.
Personal Information
Name
*
First
Last
Email
Enter Email
Confirm Email
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Angola
Anguilla
Antarctica
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Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
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Cook Islands
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Guyana
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Isle of Man
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
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Namibia
Nauru
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Netherlands
New Caledonia
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Niger
Nigeria
Niue
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North Korea
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Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
How often do you check e-mail?
Home Phone
Work Phone
Mobile Phone
Age
Height
Date of Birth
Month
Day
Year
Place of Birth
Current weight
Weight six months ago
Weight one year ago
Would you like your weight to be different?
Yes
No
What would you like to weigh?
Social Information
Relationship status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week?
Health Information
Please list your main health concerns
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illnesses/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
What is your blood type?
How is your sleep?
How many hours do you sleep on average a night?
Do you wake up at night?
Yes
No
Why?
Any pain, stiffness or swelling?
Yes
No
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
Reached or approaching menopause? Please explain:
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain:
Medical Information
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?
On a scale of 1 to 10, how would you rate the amount of stress in your life?
1 being very low stress, 10 being very high stress
Please select one
1
2
3
4
5
6
7
8
9
10
Food Information
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
Yes, all the time
Sometimes
Rarely
Never
What percentage of your food is home-cooked?
From where do you get the rest of your meals?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
Additional Comments
Anything else you would like to share?