Womens health form WOMEN'S HEALTH FORM First Name * Last Name * Your Email * How often do you check email? Phone Age Height Birthdate Place of Birth Current Weight: Weight 6 months ago? Weight One Year Ago? Would you like your weight to be different? Why? Relationship Status: Where do you currently live? Children? Pets? —–HEALTH INFORMATION—- Please list your main health concerns? Other concerns/goals? At what point in your life do you feel best? Any serious illnesses/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 pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: Are your periods regular? How many days is your flow? How Frequent? Painful or symptomatic? Please Explain: Birth Control History Reached or approaching menopause? Please Explain: 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? What foods did you eat often as a child? 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 the time? 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: What is the number one area you struggle with in relation to health and wellness? In creating your health and wellness results, what would you love? (Goals) On a scale of 1-10, how motivated are you to make a change? Feel free to comment. Why are you seeking support now and not 6 months or a year ago? Occupation? Does your work require high energy expenditure or are you sedentary? Please briefly describe: Does your schedule effect your ability to eat regularly? If yes, briefly explain: Does your schedule effect your ability to maintain a regular sleeping schedule? If yes, briefly explain: If you knew you could achieve your results, are you willing to make a financial, emotional and time commitment? The fastest way to achieve your results is through personalized coaching. My price points for my coaching services are in the range of about a buck a day to a few bucks daily. Are you interested in investing in yourself with personalized coaching? Anything else you would like to share? What does your life look like? Rate each area of your life on a scale between 1-10. (10 being the highest) Joy 12345678910 Spirituality 12345678910 Creativity 12345678910 Health 12345678910 Career 12345678910 Finances 12345678910 Relationships 12345678910 Home Environment 12345678910 Home Cooking 12345678910 Social Life 12345678910 Education 12345678910 Physical Activity 12345678910 Δ