Women’s Health History

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

Personal Information

First Name (required)

Last Name (required)

Your Email (required)

How often do you check email?

Home Phone:

Work Phone:

Mobile Phone:



Birth Date:

Place of Birth

Current weight

Weight 6 months ago

Weight one year ago

Would you like your weight to be different?

If so, what?

Social Information

Relationship Status

Where do you currently live?




Hours of work per week?

Health Information

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 ancestry?

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?


Any pain, stiffness or swelling?

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:


Allergies or sensitivities? Please explain:

Medical Information

Do you take any supplements or medications?

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 food do you eat often as a child?






What is your food like these days?






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?

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