Contact

Rebecca Stewart

Forever Healthy offers personal consultations and strategic wellness designs
to various individuals online. My name is Rebecca Stewart, and in as little as 60 minutes,
you will get coaching that fits your food and lifestyle needs!
Reach out to me today for any questions.

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Get Started on The New You!

Women's Health Form
Men's Health Form
Senior's Health Form
Female Teen Form
Male Teen Form
Children's Teen Form

Women's Health Form

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

This field is for validation purposes and should be left unchanged.

PERSONAL INFORMATION

Name

First Name: Last Name:

Email:

How often do you check email?

Phone: Home:

Work:

Mobile:

Age:

Height:

Birthdate:

MM slash DD slash YYYY

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

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 blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

WOMEN’S HEALTH

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic? 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?

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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?

What percentage of your food is home-cooked?

Where do you get the rest from?

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?

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Men's Health Form

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

PERSONAL INFORMATION

Name

First Name: Last Name:

Email:

How often do you check email?

Phone: Home:

Mobile:

Work:

Age:

Height:

Birthdate:

MM slash DD slash YYYY

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

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 blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? 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?

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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?

What percentage of your food is home-cooked?

Where do you get the rest from?

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

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

ADDITIONAL INFORMATION

Anything else you would like to share?

CAPTCHA

Senior's Health Form

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

PERSONAL INFORMATION

Name

First Name: Last Name:

Email:

How often do you check email?

Best number to reach you:

Age:

Height:

Date of Birth:

MM slash DD slash YYYY

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

SOCIAL INFORMATION

Relationship status:

Where do you currently live?

Grandchildren:

Occupation:

Hours of work per week:

What is your retirement plan?

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 blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? 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 does exercise play in your life?

What is your energy like?

Do you still feel independent? Please explain:

Are you part of a community? Please explain:

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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?

What percentage of your food is home-cooked?

Where do you get the rest from?

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?

CAPTCHA

Female Teen Form

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

PERSONAL INFORMATION

Name

First Name: Last Name:

Email:

How often do you check email?

Phone: Home:

Work:

Mobile:

Age:

Height:

Birthdate:

MM slash DD slash YYYY

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

Why did you come for a Health History?

SOCIAL INFORMATION

What is your relationship status?

What grade are you in?

Do you enjoy school? Please explain:

Do you have a large or small group of friends?

HEALTH INFORMATION

Please list your main health concerns:

Other concerns?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

Where do your parents and grandparents come from?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

FEMALE TEEN HEALTH

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic? Please explain:

What is your birth control history?

Do you experience yeast infections or urinary tract infections? Please explain:

MEDICAL INFORMATION

Are you concerned with body image? Please explain

Do you take any supplements or medications? Please list:

Do you have any healers, helpers, therapies, or pets? Please list:

What role does exercise, sports, and activities play in your life?

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

What percentage of your food is home-cooked?

Do you enjoy the food?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or drugs? Please explain?

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

ADDITIONAL INFORMATION

Anything else you would like to share?

CAPTCHA

Male Teen Form

Please write or print clearly. All of your information will remain confidential between you and the Health Coach.

PERSONAL INFORMATION

Name

First Name: Last Name:

Email:

How often do you check email?

Phone: Home:

Mobile:

Age:

Height:

Date of Birth:

MM slash DD slash YYYY

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

Why did you come for a Health History?

SOCIAL INFORMATION

What is your relationship status?

What grade are you in?

Do you enjoy school? Please explain:

Do you have a large or small group of friends?

HEALTH INFORMATION

Please list your main health concerns:

Other concerns?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

Where do your parents and grandparents come from?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

MEDICAL INFORMATION

Do you take any supplements or medications? Please list:

Do you have any healers, helpers, therapies, or pets? Please list:

What role does exercise, sports, and activities play in your life?

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

What percentage of your food is home-cooked?

Do you enjoy the food?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or drugs? Please explain?

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

ADDITIONAL INFORMATION

Anything else you would like to share?

CAPTCHA

Children's Teen Form

Please write or print clearly. All information listed will remain confidential between child, parent and Health Coach.

URL

This field is for validation purposes and should be left unchanged.

PERSONAL INFORMATION

Name

First Name: Last Name:

Phone:

Email or parents’ email:

Age:

Birthdate:

MM slash DD slash YYYY

Place of Birth:

Height:

Weight:

Grade:

Why did you come for this health history?

SOCIAL INFORMATION

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?

What is your favorite sport or activity?

What are fun things you do with family?

What are your favorite things to do when you are alone?

What chores do you do around the house?

HEALTH INFORMATION

When is bedtime?

When do you wake up?

Do you ever wake up at night?

Do you ever have nightmares?

Do you get bellyaches?

Do you get headaches or earaches?

Is it hard to see or read?

Do you get itchy?

MEDICAL INFORMATION

Do you have allergies or sensitivities?

Does anything else hurt?

FOOD INFORMATION

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 do you want to learn about your body and about food?

ADDITIONAL INFORMATION

Do you have anything else you would like to share?

CAPTCHA

Contact

Rebecca Stewart

Your Details

Comments / Questions

Get Started on The New You!

Women's Health Form

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

WOMEN’S HEALTH

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL COMMENTS

Men's Health Form

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL INFORMATION

Senior's Health Form

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL COMMENTS

Female Teen Form

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

FEMALE TEEN HEALTH

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL INFORMATION

Male Teen Form

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL INFORMATION

Children's Teen Form

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL INFORMATION

Rebecca Stewart, Integrative Nutrition Health Coach