Women’s Health History Women's Health HistoryAll of your information will remain confidential between you and the Health Coach. First Name: Last Name: E-mail: How often do you check e-mail: Home Phone: Work Phone: Mobile Phone: Date of Birth:01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Place of Birth: Height: Current weight: Weight six months ago: 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: Birth control history: Reached or approaching menopause? Please explain: 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?:What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquids: Breakfast/current:What is your food like these days? Lunch/current: Dinner/current: Snacks/current: Liquids/current: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?: Do you crave sugar, coffee, cigarettes, or have any major addictions?: The most important thing I should do to improve my health is: Do you cook?: What percentage of your food is home-cooked?: Where do you get the rest from?: Anything else you would like to share?:SubmitReset
