All of your information will remain confidential between you and the Health Coach. Women's Health History Personal InformationName First Last Email How often do you check e-mail?Home PhoneWork PhoneMobile PhoneAgeHeightBirthdate Place of BirthCurrent WeightWeight six months agoWeight one year agoWould you like your weight to be different?If so, what?Social InformationRelationship statusWhere do you currently live?ChildrenPetsOccupationHours of work per weekHealth InformationPlease list your main health concernsOther 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:Reached or approaching menopause? Please explain:Birth control history:Do you experience yeast infections or urinary tract infections? Please explain:Medical InformationDo 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?Food InformationWhat foods did you eat often as a child? BREAKFASTWhat foods did you eat often as a child? LUNCHWhat foods did you eat often as a child? DINNERSnacksLiquidsWill 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:What is your food like these days? BREAKFASTWhat is your food like these days? LUNCHWhat is your food like these days? DINNERSnacksLiquidsAdditional CommentsAnything else you would like to share?