Women’s Health History

All of your information will remain confidential between you and your Health Coach.

Personal Information

First Name:*

Last Name:*

Home Phone:

Work Phone:

Cell Phone:

Email:*

How often do you check email?

Age:

Birthdate:

Place of Birth:

Height:

Current Weight:

Weight 6 months ago:

Weight 1 year ago:

Would you like your weight to be different? YesNo

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 is your blood type?

How is your sleep?

Hours of sleep?

Do you wake up at night?YesNo

Reason?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

Are your periods regular?YesNo

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 often eat as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What foods did you now eat?

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?

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

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

Additional Comments

Anything else you would like to share?

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