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New Client Form (women)
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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
*
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Work Phone Number
*
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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
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Other concerns and/or goals?
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is/was the health of your mother?
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How is/was the health of your father?
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How healthy are the other people in your current household (partner, children, etc.)?
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What is your ancestory?
*
What blood type are you?
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How is your sleep?
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How many hours?
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Do you wake up at night?
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How often? Why?
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Any pain stiffness or swelling?
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Any constipation/diarrhea/gas?
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Allergies or sensitivities? Please explain:
*
Are you periods regular?
*
How many days in your flow?
*
How frequent?
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Painful or symptomatic? Please explain:
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Reached or approching menopause? Please explain:
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What is your birth control history?
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Do you experience yeast infections and/or urinary tract infections? Please explain:
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Medical information
Do you take any supplements or medications? Please list:
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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:
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Where do you get the rest of your food from?
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Do you crave sugar, coffee, cigarettes or have any major addictions?
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What is the most important thing you could change about your diet to improve your health?
*
Submit