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Women’s Health History Form

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

Personal Information

First Name
Last Name
Email
How often do you check e-mail?
Home Phone
Work Phone
Mobile Phone
Place of Birth
Age
Birthdate
Height
Current Weight
Weight 6 Months Ago
Weight 1 Year 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
Other concerns and/or goals?
At what point in your life did you feel 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?
What blood type are you?
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? 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 explain.

 
 

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 foods did you eat often as a child?

Breakfast
Lunch
Dinner
Snacks
Liquids
Other

 

What is your food like these days?

Breakfast
Lunch
Dinner
Snacks
Liquids
Other

 

Additional Food Information

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 addictions?
The most important thing I should do to improve my health is?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

 

Additional Comments

Anything else you would like to share?