Women’s Health History

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

Personal Information

First Name(Required)

Last Name(Required)

Age(Required)

Email(Required)

Birthdate

Place of Birth

Phone number(Required)

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?

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