New Client Form (women)

Women's Health History

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

Personal Information

Name *

First

Last

Email *

How often do you check email? *

Mobile Phone Number *

Work Phone Number *

Age *

Birthdate *

Place of Birth *

Height *

Current weight *

Weight six months ago *

Would you like your weight to be different? *

If so, what? *

Social Information

Relationship status *

Children (names and ages) *

Pets *

Where do you currently live? *

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? *

How healthy are the other people in your current household (partner, children, etc.)? *

What is your ancestory? *

What blood type are you? *

How is your sleep? *

How many hours? *

Do you wake up at night? *

How often? Why? *

Any pain stiffness or swelling? *

Any constipation/diarrhea/gas? *

Allergies or sensitivities? Please explain: *

Are you periods regular? *

How many days in your flow? *

How frequent? *

Painful or symptomatic? Please explain: *

Reached or approching menopause? Please explain: *

What is your birth control history? *

Do you experience yeast infections and/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 as a child?

Breakfast: *

Lunch *

Dinner: *

Snacks *

Liquids *

What is your food like these days?

Breakfast: *

Lunch: *

Dinner *

Snacks *

Liquids *

Will family/friends be supportive of your desire to make food and/or lifestyle changes? Please explain: *

Who cooks in the household? Please explain: *

Where do you get the rest of your food from? *

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

What is the most important thing you could change about your diet to improve your health? *

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