Women's Health History

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

Full Name *
Email Address *
Phone *
Weight
Birthdate
Weight 6 Months Ago 
would You like your weight to be different? If So, describe how:
Please List Your Main Health Concerns:
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At what point in your life did you feel your best? 
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How is your sleep? How many hours? Do you wake-up at night? If so, why? 
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Any pain, Stiffness or Swelling?
Any Allergies or Sensitivities? Please explain
Constipation/Diarrhea/Gas?
Please describe your cycle. Regularity? Length? Frequency? Approaching or Reached Menopause?
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Please list supplements or medications you take:
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Please list healers, practitioners or therapists with whom you're working:
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What role do sports and exercise play in your life?
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What is your food intake these days? (Please describe examples of breakfast, lunch, dinner, snacks)
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What percentage of food is home cooked?
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The most important thing to do to improve my health is:
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Anything else you would like to share?
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