Women's Health History
All of your information will remain confidential between you and the Health Coach.
Personal Information
Name:
First Name
Last Name
Email:
example@example.com
How often do you check e-mail?:
Home Phone:
-
Area Code
Phone Number
Work Phone:
-
Area Code
Phone Number
Mobile Phone:
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Area Code
Phone Number
Age:
Height:
Birthdate:
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Month
-
Day
Year
Date
Place of birth:
Type a question
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?If so, what?:
Social Information
Relationship Status:
Where do you currently live?:
Children:
Type a question
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?:
Constipation/ diarrhea/Gas?
Do you wake up at night? Why?:
Any pain, stiffness or swelling?:
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:
Food Information
What 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?
Print Your Name
Date
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Month
-
Day
Year
Date
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