Women's Health History Form

Please fill out to the best of your knowledge. Honesty is encouraged. All of your information will remain confidential between you and the Health Coach.
PERSONAL INFORMATION
Name
First NameLast Name
Email
example@example.com
How often do you check email?
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Age
Height
Birthdate
Place of Birth
Current Weight
Weight 6 months ago
Weight one 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:
At what point in your life did you feel your best?
Any serious injuries or hospitalizations? If so, when?
HEALTH INFORMATION
How is/was the health of your mother?
How is/was the health of your father?
How is your sleep?
How many hours?
Do you wake up at night?
If you wake up at night, why? How often?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or Sensitivities (including food) please explain:
WOMEN'S HEALTH
Are your periods regular? yes or no

How many days is your flow?number of days How frequent? Frequency
Painful or symptomatic? 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/or exercise play in your life?
FOOD INFORMATION
What foods did you often eat as a child?
Breakfast Lunch Dinner Snacks Liquids
Example 1
Example 2
Example 3
What is your food like these days?
Breakfast Lunch Dinner Snacks Liquids
Example 1
Example 2
Example 3
Will Family or friends be supportive of your desire to make food and/or lifestyle changes? If so, who are you main supports?
Do you cook? yes or no
What percentage of your food is home cooked? blank
Where do you get the rest from? 1
Do you crave sugar, coffee, cigarettes, or have any major addictions? If so, what role do they play in your life?
The most important thing I should do with my health is:
ADDITIONAL COMMENTS
Is there anything else you would like to share?
2007, 2013 Integrative Nutrition, Inc. | Reprinted with permission
Should be Empty:

	Breakfast	Lunch	Dinner	Snacks	Liquids
Example 1
Example 2
Example 3

	Breakfast	Lunch	Dinner	Snacks	Liquids
Example 1
Example 2
Example 3

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

WOMEN'S HEALTH

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL COMMENTS