Women’s Health History

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

Personal Information
First Name*
Last Name*
Age*
Email*
Birthdate
MM
DD
YYYY
Place of Birth
Phone number*
Current weight
Weight six months 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
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain
Any serious illnesses/hospitalizations/injuries?
Are your periods regular?
Painful or symptomatic? Please explain
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? (If you know)
Perimenopausal/menopausal? Please explain.
Do you experience yeast infections or urinary tract infections? Please explain
Birth control history
How is your sleep?
How many hours?
Do you wake up at night? If so, why?
At what point in your life did you feel best?
Medical Information
Do you take any supplements or medications? Please list
What role do sports and exercise play in your life?
Any healers, helpers or therapies with which you are involved? Please list
Food Information
What foods did you eat often as a child?
What is your food like these days?
Breakfast foods as a child:
Breakfast foods these days:
Lunch foods as a child:
Lunch foods these days:
Dinner foods as a child:
Dinner foods these days:
Snack foods as a child:
Snack foods these days:
Liquids as a child:
Liquids these days:
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 thing I should do to improve my health is
Additional Comments
Anything else you would like to share?

Women’s Health History

Personal Information

Social Information

Health Information

Medical Information

Food Information

Additional Comments