Women's Health Form - Personal, Health and Food Information First Name Last Name Email How often do you check email? Home Phone Work Phone Mobile Phone Age Height Birthdate (Month/Day/Year) Place of Birth Current Weight Weight six months ago Weight 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 of sleep do you get a night? 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 are your periods? Are your periods 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 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, please explain. 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 get the rest of your food 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 does your breakfast look like these days? What does your lunch look like these days? What does your dinner look like these days? What do your snacks look like these days? What does your liquid intake look like these days? Additional comments or anything else you'd like to share? 4 + 11 = Submit All of your information will remain confidential between you and the Health Coach.