Women's Health History Intake Form
Please type in your responses below. Your information will remain confidential between you and your Health Coach.
Sign in to Google to save your progress. Learn more
Email *
Name *
Cell Phone (Please enter in the following format 123-456-7890) *
City/State *
Date of Birth: *
MM
/
DD
/
YYYY
Age *
Height *
Current Weight *
Weight 6 Mo. Ago *
Desired Weight *
Would you like your weight to be different?   If so, how? *
SOCIAL: 1. Relationship Status 2. Where do you live? 3. Do you have children? 4. Do you have pets? 5. What is your occupation? 6. How many hours do you work per week? 7. What is your retirement plan?  
GENERAL HEALTH: 1. What are your main health concerns? 2. Any other concerns and/or goals? 3. At what point in your life did you feel your best? 4. Any current or previous serious illnesses, hospitalizations, or injuries? 5. How is/was your mother’s health? 6. How is/was your father’s health?  7. What is your race?  8. What is your blood type? 9. How is your sleep?  10. How many hours do you sleep per night?  11. Do you wake up during the night? If so, why? 12. Any pain, stiffness, or swelling? 13. Any constipation, diarrhea, or gas? 14. Any allergies or sensitivities?  
WOMEN ONLY: 1. Are your periods regular? 2. How many days is your flow? 3. How frequent? 4. Are your periods painful or symptomatic? If so, please explain. 5. Have you reached or are you approaching menopause? If so, please explain. 6. What is your birth control history?  7. Do you experience yeast infections or urinary tract infections? If so, please explain.
MEDICAL: 1. List all supplements or medications. 2. Are you involved with any healers, helpers, or therapies? 3. What role does exercise play in your life? 4. What is your energy like?
FOOD: 1. Will your family and friends be supportive of your desire to make food and/or lifestyle changes? 2. Do you cook? What percentage of your food is home-cooked? 3. Where does your non-home-cooked food come from?
FOOD: What foods did you eat often as a child?Breakfast. Lunch. Dinner. Snacks. Liquids.
FOOD: What foods do you typically eat these days? Breakfast. Lunch. Dinner. Snacks. Liquids.                      Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
COMMENTS: Is there anything else you would like to share?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms