Women’s Health History All of your information will remain CONFIDENTIAL between you and your Health Coach. Your Name (required) Your Email (required) Age Height Your birth date Your place of birth Your home phone Your mobile phone Your current weight Your weight 6 months ago Your weight 1 year ago Would you like it to be different? If so, what SOCIAL INFORMATION: Relationship status Where do you currently live? Children Pets Occupation Hours per week? HEALTH INFORMATION: Please list your main health concerns Other concerns or goals? At what point did you feel your best? Any serious illnesses, hospitalizations, injuries? How is/was the health of your mother? How is/was the health of your father? What is your ancestry? Blood type How is your sleep? How many hours? Do you wake up at night? Why? Any pain, stiffness, or swelling? Constipation, diarrhea, gas? Allergies, or sensitivities? Are your periods regular? How many days in your flow? How frequent? Painful or symptomatic? Birth control history? Do you experience yeast infections or urinary tract infections? Please explain MEDICAL INFORMATION Do you take any supplements or medications? Please list Any healers, helpers, or therapies with which you're involved? please list What role do sports and exercise play in your life? FOOD INFORMATION: What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids What is your food like these days? Breakfast Lunch Dinner Snacks Liquids Will your friends, family be supportive of your desire to make food and or healthy lifestyle changes? Do you cook? What percent 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 should do to improve my health is? ADDITIONAL COMMENTS: Anything else you'd like to share?