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?

Please note: I reserve the right to delete comments that are snarky, offensive, or off-topic. If in doubt, read My Comments Policy.