Women's Health Form

First Name

Last Name

How often do you check your emails?

Home Phone

Work Phone

Mobile Phone

Age

Height

Birthday

Place of birth

Current Weight

Weight 6 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 illness/hospitalizations/injuries

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestory?

What blood type are you?

How is your sleep?

How many hours do you sleep?

Do you wakeup at night?

Reasons for waking up?

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?

Reached or approaching menopause?

Birth Control History?

Do you experience yeast infections or UTI? Please explain:

Please list your supplements or medications

Any healers, helpers or therapists which you are involved? Please list:

What role do sports and exercise play in your life?

What foods did you eat often as a child: Lunch?

Breakfast

Dinner

Snacks

Liquids?

Will your family and friends be supportive in your 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

Anything else you would like to share?

Print your name

Your Signature

I CONSENT In my Intake Forms and assessment forms, I ask for some limited health history from you. I ask these questions because health coaching guidance can be more useful if I know the overall context. In addition, I may want to encourage and advise you to consult with your medical professionals for any disease conditions. I may refer you to various networks of healthcare professionals, and therefore it will be easier if I have a more complete record of your overall wellness. I am only providing coaching guidance— focusing on lifestyle, habits, and goals—and never giving you medical or psychological advice about the underlying condition.

Women's Health Form

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The Website content is educational and informational in nature and is not medical, psychological, or nutritional advice, opinion, diagnosis, treatment, or guarantee. The information contained herein does not create a professional relationship between you and I.

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