Female Health History

Email: *

What do you eat for snacks?

Cell Phone

Please list any healers, helpers or therapies with which you are involved.

How is/was the health of your mother?

Are your periods regular? How many days is your flow? How frequent? Painful or symptomatic?

Please list your main health concerns:

What foods did you eat often for lunch as a child?

How is your sleep? How many hours do you typically sleep a night? Do you wake up at night? Please explain

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

What percentage of your food is home-cooked?

Would you like your weight to be different? Explain

What liquids did you drink often as a child?

Relationship Status

Single

Married

Divorced

Additional Comments - Anything else you would like to share?

What is your blood type?

Weight 1 yr ago

Other concerns and/or goals:

Weight 6 months ago

Current Weight

Occupation

Hours of work per week

Where do you live?

What liquids do you drink?

Name

Date of Birth *

How is/was the health of your father?

How often do you check your email?

Do you have any allergies or sensitivities? Explain

Women's Health History Form

All of your information will remain confidential between you and your health coach.

Please complete the form below (fields marked " * " are required) and click submit

Any serious illnesses/hospitalizations/injuries?

Do you cook?

At what point in your life did you feel best?

What foods did you eat often for dinner as a child?

The most important thing I should do to improve my health is:

Where do you get the rest from?

What role do sports and exercise play in your life?

Children

Do you crave sugar, coffee, cigarettes or have a major addiction? Explain

What foods did you eat often for breakfast as a child?

Home Phone *

Any pain, stiffness or swelling?

What foods did you eat often for snacks as a child?

Reached or approaching menopause? Explain

Constipation/Diarrhea/Gas?

What do you eat for lunch?

Pets

Name: *

What do you eat for breakfast?

Height

Do you take any supplements or medications? Please list

What do you eat for dinner?