Women's Health History All of your information will remain confidential between you and the Health Coach. Personal Information First Name: * Last Name: * Email: * How often do you check e-mail: Home Phone: Work Phone: Mobile Phone: Age: Height: Birthdate: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905 Place of 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: 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 do sports and exercise play in your life?: 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?: Leave this field blank CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions.