Women's Health History / Michele M. Rizzo / Holistic Health Coach

Date

PERSONAL INFORMATION

First Name

Last Name

US Phone

- -

Date of Birth

FAMILY & SOCIAL INFORMATION

Relationship Status:

Children - Please list Names & Ages

Pets - Please list name(s)

Occupation & Where Employed:

Hours of work per week:

List Hobbies & Favorite Activities:

HEALTH INFORMATION

Please list your main health concerns:

What is main goal for Health Coaching:

The most important thing I should do to improve my health is:

Other concerns and/or goals?

At what point in your life did you feel best?

Any serious illness/hospitalizations/injuries?

Any known allergies or food sensitivities? Please explain:

Constipation/Diarrhea/Gas? Please explain:

Are you satisfied with your weight? Please describe:

WOMEN"S HEALTH

Reached or approaching menopause? Please explain:

If still menstruating - Are your periods regular? Please describe frequency & flow:

Painful or symptomatic? 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:

How active are you? What do you do for exercise?

FOOD INFORMATION

Please list typical foods eaten for each meal:

Breakfast

Lunch

Dinner

Typical snacks & treats

Do you cook? How often do you eat home-cooked meals?

Where do you get the rest of your meals?

Are family members or roommates supportive of healthy choices?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

Anything else you would like to share?

Women's Health History