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Women’s Health

Women's Health History
  • All of your information will remain confidential between you and the Health Coach.
    Personal Information

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  • First Name:*
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  • Last Name:*
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  • Email*
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  • How often do you check e-mail:*
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  • Home Phone:*
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  • Work Phone:*
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  • Mobile Phone:*
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  • Age:*
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  • Height:*
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  • Birthdate:*
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  • Place of Birth:*
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  • Current weight:*
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  • Weight six months ago:*
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  • One year ago:*
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  • Would you like your weight to be different?:*
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  • If so, what?:*
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  • Social Information

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  • Relationship status:*
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  • Where do you currently live?:*
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  • Children:*
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  • Pets:*
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  • Occupation:*
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  • Hours of work per week:*
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  • Health Information

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  • 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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  • What is your ancestry?:*
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  • 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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  • Why?:*
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  • Any pain, stiffness or swelling?:*
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  • Constipation/Diarrhea/Gas?:*
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  • Allergies or sensitivities? Please explain:*
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  • Are your periods regular?:*
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  • How many days is your flow?:*
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  • How frequent?:*
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  • Painful or symptomatic? Please explain:*
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  • Birth control history:*
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  • Reached or approaching menopause? Please explain:*
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  • Do you experience yeast infections or urinary tract infections? Please explain:*
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  • Medical Information

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  • 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:*
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  • What role do sports and exercise play in your life?:*
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  • Food Information

    What foods did you eat often as a child?
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  • Breakfast:*
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  • Lunch:*
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  • Dinner:*
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  • Snacks:*
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  • Liquids:*
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  • What is your food like these days?
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  • Breakfast:*
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  • Lunch:*
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  • Dinner:*
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  • Snacks:*
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  • Liquids:*
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  • Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:*
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  • Do you cook?:*
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  • What percentage of your food is home-cooked?:*
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  • Where do you get the rest from?:*
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  • Do you crave sugar, coffee, cigarettes, or have any major addictions?:*
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  • The most important thing I should do to improve my health is:*
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  • Additional Comments
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  • Anything else you would like to share?:*
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