Female Form

Female’s Health History

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

Personal Information

First Name :

Last Name :

Your Email:

How often do you check e-mail:

Home Phone:

Work Phone:

Mobile Phone:

Age :

Height:

Birth date:

Place of your birth

current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different? :

if so, what?

Social Information

Relationship Status:

Where do you currently live?:

Children:

Pets:

Occupation:

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 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:

Food Information

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

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:

What is your food like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments

Anything else you would like to share?:


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