Women’s Health History Form

All of your information will remain confidential between you and your Health Coach.

Fill out to the best of your ability

Personal Information

First Name *

Last Name *

Birthdate

Age

Height

Email *

How often do you check e-mail

Home Phone

Work Phone

Mobile Phone

Place of Birth

Current weight

Weight six months ago

One year ago

Would you like your weight to be different?

NoYes

If so, what?

Social Information

Relationship status

Where do you currently live?

Pets

Children

Occupation

Hours of work per week

Health Information

Please list your main health concerns

Any pain, stiffness or swelling?

Other concerns and/or goals?

Constipation/Diarrhea/Gas?

At what point in your life did you feel best?

Allergies or sensitivities? Please explain

Any serious illnesses/hospitalizations/injuries?

Do you experience yeast infections or urinary tract infections?

Are your periods regular?

How many days is your flow, and frequency?

Painful or symptomatic?

Reached/approaching menopause?

Birth control history

How is/was your mothers health?

How is/was your fathers health?

What is your ancestry?

What blood type are you?

How is your sleep?

Wake up at night?

If so, why?

Medical Information

Do 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 Information

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Moving forward and growing:

Will family and/or friends be supportive?

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:

Additional Comments

Anything else you would like to share?

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Women’s Health History Form

Fill out to the best of your ability

Personal Information

Social Information

Health Information

Medical Information

Food Information

What foods did you eat often as a child?

What is your food like these days?

Moving forward and growing:

Additional Comments

Verification

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