Women's Health

FORM

RECLAIM YOUR PEAK
mind • body • spirit

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

PERSONAL INFORMATION

Name

First Name

Last Name

Email Address

How Often do you check email?

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Work Phone

(###)

###

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Personal Information

Age

Birthdate

YYYY

Place of Birth

Height

Current Weight

Weight 6 Months Ago

Weight 1 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 of the following

Pain

Stiffness

Swelling

Digestion

Constipation

Diarrhea

Gas

Allergies or Sensitivities? Please explain:

Are you periods regular?

How many days is your flow?

How frequent is your period?

Painful or sympotmatic? 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

Breakfast foods a child:

Lunch foods as a child:

Dinner foods as a child:

Snacks as a child:

Liquids/Drinks as child:

Current food preferences

Breakfast

Lunch

Dinner

Snacks

Liquids

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

Where do you get rest from?

What percentage of your food is home-cooked?

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

The most important thing I should do to improve my health is:

additional Comments

Comments

RECLAIM YOUR PEAK mind • body • spirit

PERSONAL INFORMATION

RECLAIM YOUR PEAK
mind • body • spirit