WOMEN’S HEALTH HISTORY FORM

Fill out as much of this form as comfortable for you; all topics can be verbally discussed during our 1:1 discovery call that takes place once the form’s submitted.

Personal Information

Print your full name(required)

Email(required)

Mobile Phone:(required)

Birth Year:(required)

What are you interested in achieving from a wellness program?:

Place of Birth:

What is your ancestry?:

Height:

Current weight:

Weight six months ago & One year ago:

Would you like your weight to be different?:

If so, what?:

Social Information

Relationship status:

Children:

Where do you live? (Town, State or Country):

Pets:

Occupation:

Hours of work per week:

The most important thing I'd like to do to improve my health is:

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?:

Health Information

Please list your main health concerns:(required)

Health goals?:(required)

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

Any serious illnesses/hospitalizations/injuries?:(required)

Do you crave sugar, coffee, cigarettes, or have any major addictions?:

How is your sleep?:(required)

How many hours?:(required)

Do you wake up at night? + if so why:

Any pain, stiffness or swelling?:

Constipation/Diarrhea/Gas?:

Allergies or sensitivities? Please explain:

Women’s Health

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 Information

Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list:

What role does movement play in your life?:

Optional to fill out the rest *** (will discuss verbally on our discovery call)

Food Information – History

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Food Information – Present

What is your food like these days?