Women's Health History
All of your information will remain confidential between you and the Health Coach.
First name:
Last name:
Email:
Phone Number:
Address:
What is your age:
What is your height:
Birthdate:
Place of birth:
Current weight:
Weight 6 months ago:
Weight one year ago:
Would you like your weight to be different?:
If so, what?:
Social Information
Relationship status:
Single
Married
Divorced
Widowed
Have children? How many?
Have 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?:
If yes, why?:
Any pain, stiffness or swelling?:
Constipation/Diarrhea/Gas?:
Allergies or sensitivities? Please explain:
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:
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?:
Select an option
25 percent
50 percent
75 percent
100 percent
If not 100%, 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:
What is your food like these days?:
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Additional Comments
Anything else you would like to share?
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