Women’s Health History

Women’s Health History
PLEASE WRITE OR PRINT CLEARLY. ALL OF YOUR INFORMATION WILL REMAIN CONFIDENTIAL BETWEEN YOU AND THE HEALTH COACH. WE ARE NOT MEDICAL DOCTORS; therefore, we do not diagnose illness or prescribe pharmaceuticals. We are nutritional consultants and make suggestions relating to nutrition. NON of the information offered here is intended to replace any program that your medical doctor has prescribed for you, nor conflict with any pharmaceutical medication you are taking. It is recommended that you take our products at least one hour prior to taking your medication, so that the minerals offered can be fully assimilated.
Personal Information
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Name

First NameLast Name
Email Address
How often do you check your email?
Telephone - Home
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Age
Height
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Birth
Current Weight (lbs)
Weight Six Months Ago (lbs)
Weight One Year Ago (lbs)
Social Information
Relationship Status
Where do you currently live?
Number of Children
Pets
Please list type and number of pets, if applicable.
Occupation
Hours of work per week
Health Information
Please list your main health concerns
Other concerns and/or goals
How long ago have you had these challenges?
Any serious illness/hospitalizations/injuries?
What is your stress level in a scale of 1-10?
How is/was the health of your mother?
How is/was the health of your father?
What blood type are you?
How is your sleep?
How many hours do you sleep?
Do you wake up at night?
Why do you wake up at night?
Any pain, stiffness, or swelling?
Constipation / diarrhea / gas?
How often do you stool?
Allergies or sensitivities (please explain)
Are your periods regular?
How many days is your flow?
How frequent are your periods?
Are your periods painful or symptomatic?

Other
Period pain/symptoms details
Reached or approaching menopause?
Menopause details
Birth control history
Do you experience yeast infections or urinary tract infections?

Other
Yeast/UTI details
Medical Information
Do you take any supplements or medications? (please list)
Any healers, helpers, or therapies with which you are involved? (please list)
What roles do sports and exercise play In your life?
What is your food like these days?
Meats
Starches
Liquid foods
Vegetables
Canned foods
Other foods
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?
Anything else you want to share
Consultant Signature
Client Signature
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Women’s Health History

Personal Information

Social Information

Health Information

Medical Information