Women's Health History Form
All of your information will remain confidential between you and Health Coach Rivkie.
Personal Information
Name
First Name
Last Name
E-mail
How often do you check email?
Cell phone number
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Area Code
Phone Number
Age
Height
Birthdate
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Month
-
Day
Year
Date Picker Icon
Place of Birth
Current Weight
Weight six 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?
Do you have children? If yes, how many?
Do you have any pets? If yes, what?
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?
If yes, why?
Any pain, stiffness or swelling?
Constipation, Diarrhea or Gas?
Allergies or sensitivities? Please explain...
Women's Health
Are your periods regular?
How many days is your flow?
How frequent?
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 exercise play in your life?
Food Information
What foods did you often eat as a child?
Include Breakfast, Lunch, Dinner, Snacks, Liquids
What is your food like these days?
Include Breakfast, Lunch, Dinner, Snacks, Liquids
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?
The most important thing I should do to improve my health is:
Additional Comments
Anything else you would you like to share?
Submit
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