Women's Health History All of your information will be kept confidential between you and the Health CoachPERSONAL INFORMATION First Name *Last Name *Email *How often do you check your email? Home Phone Work Phone Cell Phone Age Height Date of Birth Place of Birth Current Weight What was your weight 6 months ago? What was your weight one year ago? Would you like your weight to be different? If so, what would you like it to be? Social InformationRelationship Status Where do you currently live? How many children do you have? How many pets do you have? What is your occupation? How many hours do you work per week? Health InformationPlease list your main health concerns Do you have any other concerns and/or goals? At what point in your life did you feel your best? Have you had any serious illnesses, injuries or hospitalization? 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 sleep? Do you wake up at night? If yes, why do you wake up? How many bowel movements do you have each day? Do you have constipation, gas or diarrhea? Do you have any pain, stiffness or swelling? Do you have allergies or sensitivities? Please explain. Do you have regular periods? How many days does your menstrual cycle last? How frequent are your menstrual cycle? Are your periods painful or symptomatic? Please explain. Have you reached or are approaching menopause? Birth Control History Do you experience yeast infections or urinary tract infections? Please explain Medical InformationDo you take supplements and/or medications? Please list. Are there any medical professionals, healers or therapies in which you are involved? Please list. What role does sports and exercise play in your life? Food/NutritionWHAT FOODS DID YOU EAT OFTEN AS A CHILD? Breakfast Lunch Dinner Snacks Liquids Will your family and friends be supportive of your desire to take responsibility for your food and lifestyle changes? WHAT DOES YOUR FOOD LOOK LIKE THESE DAYS? Breakfast Lunch Dinner Snacks Liquids How many ounces of water do you drink each day? Do you cook? What percentage of your food is home cooked? Where do you get the rest of your food from? Do you crave sugar, coffee, cigarettes or have any major addictions? The most important thing I need to do to improve my health is: Additional Comments So I can best serve you; is there anything else that I need to know about you? VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
