Women’s Health

Women's Health History

Please fill in the form below clearly and with as much detail as possible. Please be assured that all your information will remain confidential between you and the health coach.

PERSONAL INFORMATION

Your Full Name

Date of Birth

E-Mail Address

How Often Do You Check Emails?

Phone

Age

Height

Chest

Waist

Current Weight

Weight From Six Months Ago

Weight From One Year Ago

Would you like your weight to be different?

If Yes, how would you want it to be different?

SOCIAL INFORMATION

Relationship Status

Number of Children (if any)

Number of Pets (if any)

Home Address

Occupation

Hours of Work per Week

HEALTH INFORMATION

Please list your main health concerns:

Do you have any other concerns and/or health goals?

At what point in your life did you feel best?

Any serious illnesses, hospitalisations or 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?

Generally speaking, how is your sleep? (Rate from 1 to 5, 1 being bad, 5 being great)

How many hours of sleep do you get per night?

Do you wake up at night? (Y/N)

Do you know why?

Do you have any pain, stiffness or swelling?

Please explain

Do you have constipation/diarrhoea/Gas?

Please explain

Do you have any allergies or sensitivities?

Please explain

MEDICAL INFORMATION

Do you take any supplements or medications? Please list:

What role do sports and exercise play in your life?

FOOD INFORMATION

What was food like one year ago?

What is your food like these days?

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?

WOMEN'S HEALTH

Are your periods regular?

How many days is your flow?

How frequent is it?

Is it painful or symptomatic?

Please explain briefly

Have you reached or approaching menopause?

Please explain briefly if need be.

Birth control history

Do you experience yeast infections or urinary tract infections?

If so, please explain if necessary.

When was your last pap exam?

Do you have lumps in your breast?

Anything else you would like to share?

STAY IN THE LOOP

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Women’s Health

Women's Health History

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Monday - Friday 09.00 - 17.00

832-779-0188

info@newunowcourses.org

admin@newunowcourses.org

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Women’s Health

Women's Health History

STAY IN THE LOOP

Your life is about to change for the better

CONTACT US TODAY

Monday - Friday 09.00 - 17.00

832-779-0188

info@newunowcourses.org

admin@newunowcourses.org

WE'RE SOCIAL