Women's Health HistoryAll of your information will remain confidential between you and the Health Coach.
Personal InformationFirst Name: *
Last Name: *
Email: *
How often do you check e-mail:
Home Phone:
Work Phone:
Mobile Phone:
Age:
Height:
Birthdate:MonthMonthJanFebMarAprMayJunJulAugSepOctNovDec
DayDay12345678910111213141516171819202122232425262728293031
YearYear201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?:
If so, what?:
Social InformationRelationship status:
Where do you currently live?:
Children:
Pets:
Occupation:
Hours of work per week:
Health InformationPlease 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 InformationDo 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 InformationWhat 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?:
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:
What is your food like these days?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Additional CommentsAnything else you would like to share?:
Personal InformationFirst Name: *
Last Name: *
Email: *
How often do you check e-mail:
Home Phone:
Work Phone:
Mobile Phone:
Age:
Height:
Birthdate:MonthMonthJanFebMarAprMayJunJulAugSepOctNovDec
DayDay12345678910111213141516171819202122232425262728293031
YearYear201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?:
If so, what?:
Social InformationRelationship status:
Where do you currently live?:
Children:
Pets:
Occupation:
Hours of work per week:
Health InformationPlease 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 InformationDo 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 InformationWhat 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?:
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:
What is your food like these days?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Additional CommentsAnything else you would like to share?:
