Cart 0

Women's Health Form

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

Please complete the form below

Name

First Name

Last Name

Email Address

How often do you check e-mail?

Home Phone Number

Work Phone Number

Mobile Phone Number

Age

Height

I authorize my personal information to be sent for review by my Health Coach.

Yes

Year You were Born

Month You were Born

Day You were Born

Place of Birth

Current Weight

Weight Six Months Ago

Weight One year Ago

Would you like your weight to be different?

If so, what?

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of Work per Week

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?

Do you wake up at night?

Why?

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.

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?

Breakfasts You Ate often as a Child

Lunches You Ate often as a Child

Dinners You Ate often as a Child

Snacks You Ate often as a Child

Liquids You Drank often as a Child

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...

Breakfasts You are Eating These Days

Lunches You are Eating These Days

Dinners You are Eating These Days

Snacks You are Eating These Days

Liquids You are Drinking These Days

Anything else you would like to share?

I authorize my personal information to be sent for review by my Health Coach.

Yes