Women's Health History

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

Personal Information

First Name

Last Name

Email Address

How often do you check your email?

Most Used Phone

Date of Birth

Height:

Current weight:

Place of Birth:

Weight six months ago:

One year ago:

Would you like your weight to be different? If so, what?:

Social Information

Relationship status:

Where do you currently live enviormentally? Ex: All 4 seasons, Tropical, Cold Weather

Do you have children?:

Pets:

Occupation?:

Hours of work per week:

Pets:

Medical Information

Health 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?:

Please list your main health concerns:

What are your main concerns and/or goals at this time?

At what point in your life did you feel best?:

Any serious illnesses/hospitalizations/injuries?:

How is/was the health of your mother? If you know:

How is/was the health of your father? If you know:

What is your ancestry? What you know:

What blood type are you? If you know:

How is your sleep? How many hours do you feel you get? How often do you wake at night?:

Where is the pain, flaking, oozing, cuts, open wounds stiffness or swelling?:

Constipation/Diarrhea/Gas?:

Allergies or sensitivities? Please explain:

Constipation/Diarrhea/Gas?:

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, if one:

Do you experience yeast infections or urinary tract infections? Please explain:

Food Information

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:

Where do you get the rest from? Examples: Bed, Couch, Car

Do you crave sugar, coffee, cigarettes, or have any sort of addictions? Example: Shopping

The most simple thing you can do to improve your health is:

What is your food like these days?

Do you cook? If yes, please describe what portion is fresh fruits and veggies & how do you incorporate them into meals. If no, please describe what you do cook minimally? What are you eating throughout the day?:

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments

Anything else you would like to share?

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

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