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Confidential Health History Form
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Home
About Me
Integrative Nutrition Health Coach
Work with Me
Health Coach Services
My Approach
Forms
>
Revisit Form
Confidential Health History Form
Contact
Blog
Health
Recipes
Health History - Woman
PERSONAL INFORMATION
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Indicates required field
Name
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First
Last
Email
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How often do you check email?
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Cell Phone Number
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Home Phone Number
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Work Phone Number
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Age
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Height
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Birthdate
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Place of Birth
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Current Weight
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Weight 6 months ago
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1 year ago
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Would you like your weight to be different? and if so, what?
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SOCIAL INFORMATION
Relationship status:
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Where do you currently live?
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Children
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Pets
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Occupation
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Hours per week
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HEALTH INFORMATION
Please list your main health concerns
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Other concerns and/or goals?
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is the health of your mother?
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How is the health of your father?
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What is your ancestry?
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What blood type are you?
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How is your sleep?
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How many hours?
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Do you wake up at night? Why?
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Any pain, stiffness or swelling?
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Constipation/Diarrhea/Gas?
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Allergies or sensitivities? Explain
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WOMAN'S HEALTH
Are your periods regular?
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How many days is your flow?
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How frequent?
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Painful or symptomatic? Please explain
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Birth Control history:
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Do you experience yeast infections or urinary tract infections? Please explain:
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MEDICAL INFORMATION
Do you take any supplements or medications? Please list:
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Any healers, helpers or therapies with which you are involved? Please list:
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What roles do sports and exercise play in your life?
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FOOD INFORMATION
What foods did you eat often as a child?
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What is your food like these days?
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Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Yes
No
Do you cook? and What percentage of your food is home-cooked?
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Where do you get the rest of your food from that isn't home-cooked?
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Do you crave sugar, coffee, cigarettes or have any major addictions?
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The most important thing I should do to improve my health is:
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Additional Comments
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Submit