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ABOUT ME
GET STARTED
LIFESTYLE
RECIPES
CONTACT
SHOP

Women’s Health History Form

Congratulations! You’ve made an extraordinary step toward a better health and I am so happy to begin working with you.

Please complete the health history form below. Once I receive your submission I will be in touch within 24-48 hours with access to your welcome pack .

First Name(required)

Last Name(required)

Email(required)

Phone(required)

How often do you check your email?(required)

How did you hear about my Health Coaching Program? (required)

Age(required)

Height(required)

Birthday(required)

Current Weight(required)

Weight Six Months ago

Would you like your weight to be different? (required) Yes

No

If so, what would you like it to be?

What prompted you to sign up for a Health History?(required)

SOCIAL INFORMATION

Relationship status(required)

Where do you currently live?(required)

Children/Pets (required)

Occupation (required)

Hours of Work per Week(required)

HEALTH INFORMATION

Please list your main health concerns (required)

Is there anything else that's a big struggle or roadblock for you?(required)

At what point in your life did you feel your best?(required)

Any serious illnesses/hospitalizations/injuries?(required)

How is the health of your mother?(required)

How is the health of your father?(required)

What is your ancestry?

What blood type are you?

How is your sleep?(required)

How many hours per night?(required)

Do you wake up at night?(required) Yes

No

If yes, why?

Do you have any pain, stiffness or swelling?(required)

Constipation/Diarrhea/Gas? (required)

Allergies/Sensitives? If yes, please list. (required)

WOMEN’S HEALTH

Are your periods regular?(required) Yes

No

How many days is your flow?(required)

How frequent? (required)

Are they painful or symptomatic? Please explain (required)

Have you reached or approaching menopause? Please explain

Birth Control History(required)

Do you experience yeast infections or urinary tract infections? Please explain(required)

MEDICAL INFORMATION

Are you under the care of a doctor right now for any medical condition? If yes, please explain(required)

Do you take any supplements or medications? Please list.(required)

Any healers, helpers, therapies with which you are involved? Please list: (required)

What role do sports and exercise play in your life? (required)

Describe what your energy is like (required)

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast(required)

Lunch(required)

Dinner(required)

Snacks(required)

Drinks(required)

What is your food like these days?

Breakfast(required)

Lunch(required)

Dinner(required)

Snacks(required)

Drinks(required)

Do you cook?(required) Yes

No

What percentage of your food is home cooked?(required)

Where does the rest come from?(required)

Do you crave sugar, coffee, cigarettes or have any major addictions? Please explain(required)

ADDITIONAL INFORMATION

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

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

What are the top 2 or 3 things you would like help with? (required)

Why are these things important to you? (required)

What have you tried in the past and how did that go?

Would you be open to nutritional supplement recommendations to help support your needs during your program?(required) Yes

No

Anything else you would like to share?

COACHING DISCLAIMER
PRIVACY POLICY
RECIPES
FREE SESSION

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