Home
About
Work With Me
The Coaching Program
The Detox
Welcome
BeautyCounter
Resources
Contact
Home
About
Work With Me
The Coaching Program
The Detox
Welcome
BeautyCounter
Resources
Contact
Women's Health History
Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Age
*
Height
*
Birth Date
*
Place of Birth
*
Current Weight
*
Weight Six Months Ago
*
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
*
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?
*
Why?
*
Please write N/A if you answered no to the question above.
Any pain, stiffness, or swelling?
*
Constipation/Diarrhea/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?
*
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 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 like to share?
Thank you!
