Women’s Health

WOMEN’S HEALTH HISTORY

Let us know your questions, suggestions and concerns by filling out the contact form below. Your information will remain confidential between you and your Health Coach.
PERSONAL
First Name*
Last Name*
Age*
Height*
Birth Date*
Place of Birth:
Email*
How often do you check it?
Home Phone
Work Phone
Mobile Phone*
Current Weight:*
Weight Six Months Ago:
Weight One Year Ago:
Would you like your weight to be different?
If so, how?
SOCIAL
Relationship Status:
Where do you live?
Any children?
Any pets?
Occupation:
How many hours do you work per week?
GENERAL HEALTH
What are your main health concerns?*
Any other concerns and/or goals?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is/was your mother’s health?
How is/was your father’s health?
What is your ancestry?
What is your blood type?
How is your sleep?*
How many hours do you sleep per night?
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any constipation, diarrhea, or gas?
Any allergies or sensitivities?*
WOMEN’S HEALTH
Are your periods regular?
How many days is your flow?
How frequent?
Are your periods painful or symptomatic? If so, please explain:
Have you reached or are you approaching menopause? If so, please explain:
What is your birth control history?
Do you experience yeast infections or urinary tract infections? If so, please explain:
MEDICAL
List all supplements or medications:*
Are you involved with any healers, helpers, or therapies?
What role do sports and exercise play in your life?
FOOD
Will your family and 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 does your non-home-cooked food come from?
WHAT FOODS DID YOU EAT OFTEN AS A CHILD?
Breakfast
Lunch
Dinner
Snacks
Liquids
WHAT FOODS DO YOU TYPICALLY EAT THESE DAYS?
Breakfast
Lunch
Dinner
Snacks
Liquids
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
ADDITIONAL COMMENTS
Anything else you would like to share?
Name
This field is for validation purposes and should be left unchanged.

FORMS

WOMEN’S HEALTH HISTORY

PERSONAL

SOCIAL

GENERAL HEALTH

MEDICAL

FOOD

WHAT FOODS DID YOU EAT OFTEN AS A CHILD?

WHAT FOODS DO YOU TYPICALLY EAT THESE DAYS?

ADDITIONAL COMMENTS