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Women's Health Form
First Name
Last Name
Email
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
Clear
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.
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