Women’s Health History form

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

Personal Information

Name *

Name

First Name

Last Name

Email Address *

How often do you check email

Home phone

(###)

###

####

Mobile phone

(###)

###

####

Age

Height

Date of birth

Place of birth

Current weight

Weight six months ago

Weight one year ago

Would you like your weight to be different?

Yes

Unsure

If yes, to 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/hospitalization/injuries?

How is/was the health of your mother?

How is/was the health of your father?W

What is your ancestry?

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

If so, why?

Any pain, stiffness or swelling?C

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 list

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 Breakfast did you often eat as a child?

What Lunch did you often eat as a child?

What Dinner did you often eat as a child?

What Snacks did you often eat as a child?

What Liquids did you often drink as a child?

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?

Where do you get the rest from?

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

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

What is your Breakfast like these days?

What is your Lunch like these days?

What is your Dinner like these days?

What are your Snacks like these days?

What are your Liquids like these days?

Additional Comments

Anything else you would like to share?