Wellness Blooms

Health Coaching with Sharon Lees

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Confidential Health History

General Info
More General Info

When was the last time you felt vibrant and well?

If you could wave a magic wand and change 2 things about your life right now, what exactly would they be?

Any serious illness, hospitalization, injuries, and surgeries, either now or in your past?

How is the health of your mother? If deceased, relay illnesses.

How is the health of your father? If deceased, relay illnesses.

Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?

Women Only

Do you struggle with Constipation, Diarrhea, Gas, Distension, Belching, or Bloating? Which?


Please list all supplements or medications you take (prescription or over-the-counter) and frequency.

Have you ever taken antibiotics more than a short course or two as a child? If so, when/how often? For what? And for how long?

Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?

What is the general status of your dental health/care?

Any troubling dental work or history of dental/oral infections? Dentures? Root canals?

How many silver/mercury fillings do you have?

Other major dental work/issues beyond basic cleanings?


On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?

Any healers, helpers, pets or therapies with which you are involved?

What role do sports and exercise play in your life?

What was your general health and well-being as a child?

What foods did you eat often as a child?
What's your food like these days?

Do you have any known food allergies or sensitivities?

If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly.

Do you crave sugar, carbs, alcohol, coffee, cigarettes, other foods, or have any addictions?

What two single changes do you most know you need to make in order to get healthier and reach your specific goals?

What specifically stands in the way of your making the healthier choices that you know would serve you the best?

Imagine what it will be like when you reach your specific health goals. What will this allow to happen in your life? Please give two specific benefits you are particularly excited about.

Many of our client's health situations are complex and have already been investigated by several other practitioners. Sometimes the most important ah-ha in uncovering why you are struggling is an unexpected or unconventional concept. Intuitively, what do you feel is the most important pearl of information we need to understand about how or why your health is in the state that it is right now?

Symptom Questionnaire

Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two weeks. If multiple choices are given, please specify what applies in the comment column.

  • 0 - Never have the symptom.
  • 1 - Occasionally have it and the effect is mild.
  • 2 - Occasionally have it and the effect is severe.
  • 3 - Frequently or Consistently have it and the effect is Mild
  • 4 - Frequently or Consistently have it and the effect is Severe





Stuffy nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

Chronic coughing

Gagging or frequent need to clear throat

Sore throat, hoarseness, or loss of voice

Swollen or discolored tongue, gums, or lips

Chronic tooth or gum pain or jaw pain. Which?

Canker sores


Hives or other allergic breakout

Rash or persistently dry skin

Hair loss

Flushing or hot flashes

Frequently feel cold

Excessive sweating

Part of body frequently feeling numb. Which?

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Nausea or vomiting



Bloated feeling

Belching, burping

Passing gas, flatulence


Intestinal or Stomach pain. Which?

Other pain in GI tract? Where?

Pain or aches in joints


Stiffness or limitation of movement

Pain or aches in muscles

Tremor or restless leg

Feeling of weakness or tiredness

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention


Fatigue, sluggishness

Apathy, lethargy



Poor memory

Confusion, poor comprehension

Poor concentration or focus

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Learning disabilities

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness


Other mood challenges?

Frequent illness

Frequent or urgent urination

Inability to urinate or low urine flow

Low libido or other sexual dysfunction

Genital itch or discharge

Women: Breast fibroids

Women: Painful or tender breasts

Women: Uterine fibroids