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Women’s Health History

All of your information will be kept confidential between you and the Health Coach

Personal Information

First Name
Last Name
Email *
How often do you check your email?
Home Phone
Work Phone
Cell Phone
Age
Height
Date of Birth
Place of Birth
Current Weight
What was your weight six months ago?
What was your weight one year ago?
Would you like your weight to be different
If so, what would you like it to be?

Health Information

Please list your main health concerns
Do you have any other concerns and/or goals?
At what point in your life did you feel your best?
Any serious illnesses, injuries or hospitalization?
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 sleep?
Do you wake up at night?
If yes, why do you wake up?
Do you have any pain, stiffness or swelling?
Allergies or sensitivities? Please explain.
Do you have constipation, diarrhea or gas?
Are your periods regular?
How many days is your menstrual cycle?
How frequent?
Are your periods 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 supplements or medications? Please list.
Any medical professionals, healers, helpers, or therapies in which you are involved? Please list.
What role do sports and exercise play in your life?

Food/Nutrition Information

What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and friends be supportive of your desire to make food and/or lifestyle changes?
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
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 need to do to improve my health is:

Additional Comments

Is there anything else you would like to share?

Verification

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