Women’s Health History

Women's Health History

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

Personal Information

Social Information

Health Information

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 eat often as a child?

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

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 your food like these days?

Additional Comments

Anything else you would like to share?: