WMC (Tier 2)

Member Health History

As a Tier 2 member of the Wellness Mastery Circle, you’ll have access to monthly 1:1 coaching and personalized support. This health history form gives your coach a clear snapshot of your current health, goals, and lifestyle so they can better guide you during your sessions. You don’t need to share every detail, but please answer as openly and honestly as possible to help us support you in a way that feels aligned, doable, and empowering.

Date: *

First Name *

Last Name *

Date of birth *

Name of Coach (choose from dropdown): *

Phone *

Email *

Personal Information

Height: *

Current Weight: *

Goal Weight (if applicable): *

Occupation: *

Marital/Relationship Status: *

Children: (ages or “none”) *

Personal Goals:

What are your top 2–3 goals for your health/lifestyle in the next 3–6 months? *

What specific concerns would you like your coach to support you with? *

Health & Medical Background:

Are you currently under the care of any medical professionals? If yes, what type? *

Any surgeries, injuries, or major health events (past 5 years)? *

Do you have any food sensitivities or allergies? *

List any medications (name + reason for use): *

List any supplements or herbal remedies you take regularly: *

How often do you have a bowel movement? *

Symptoms - Women only (check all that apply)

(Women) Are your cycles regular?

Yes

Not Applicable (menopause)

How many hours of sleep do you get on average? *

Under 5

5–6

7–8

How often and what type of exercise do you engage in? *

Do you struggle with: *

Falling asleep

Staying asleep

Waking up groggy

None of the above

How would you describe your current food choices? *

Mostly whole foods

Some processed foods

Fast food often

Specific dietary plan (ex: GF, Paleo, Vegan)

Do you drink water daily? How much? Is it filtered? *

How would you describe your daily stress level? *

What helps you manage stress? *

Support, Mindset & Readiness:

What motivates you to make healthy changes right now? *

Is there anything else you'd like your coach to know to support you best? *

What’s been your biggest struggle with consistency in the past? *

Do you feel supported by family/friends in your wellness journey? *

Yes

Sometimes

Have you experienced any recent major life changes or stressors? *

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