Women’s Health History

Women’s Health History Form

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

Personal Information

First Name*

Last Name*

E-mail*

How often do you check your e-mail

Home Phone

Work Phone

Mobile Phone

Age

Height

Birth Date

Place of Birth

Current Weight

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different? If so, what?



Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week



Health Information

What are your main health concerns?

Other concerns and/or goals?

At what point in your life did you feel best?

Any serious illnesses/hospitalisations/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 do you sleep?

Do you wake up at night?

Why do you wake up at night?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

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



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:



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



Additional Comments

Anything else you would like to share?