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Women Health History Form
Welcome to It's All Food, Health & Fitness Coaching with Tracey. Please take a few minutes to complete this form. All submitted information is strictly confidential.
Email address *
PERSONAL INFORMATION
First and Last Name *
Email *
How often do you check your email? *
Phone: home/work/mobile *
Age *
Height *
Birthdate *
Place of Birth *
Current Weight *
Desired Weight *
Lowest Weight *
Highest Weight *
Why did you choose to come for a health consult? *
SOCIAL INFORMATION
Relationship Status *
Where do you currently live? *
Children/Age/Gender *
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 your best? Please explain. *
Are you currently pregnant? If yes, when is your due date? *
Are you trying to conceive? *
Are you breastfeeding? *
Any serious illnesses/hospitalizations/injuries? *
How is/was the health of your mother? *
How is/was the health of your father? *
Where do your parents and grandparents come from? *
How is your sleep? *
How many hours do you sleep? *
Do you wake up at night? Why? *
Do you suffer from constipation/diarrhea/gas? If so, how often? *
Do you have any allergies or food sensitivities? Please explain. *
WOMEN'S HEALTH
Are your periods regular? *
How many days is your flow? *
How frequent is your period? *
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: *
How is your energy level? *
Enjoyment of Life? *
Daily Stress Level? *
MEDICAL INFORMATION
Do you take any supplements, vitamins or medications? Please explain: *
Do you have any healers, helpers, therapists or pets? Please list: *
What role does exercise, sports and activities play in your life? *
FOOD INFORMATION
What foods did you eat often as a child? Beverages? Snacks? *
What is your food like these days? Beverages? Snacks? *
What percentage of your food is home-cooked? *
Where do you get the rest of your food? *
Do you enjoy food? *
Do you crave sugar, salt, coffee, bread, pasta, candy, sour, chocolate, meat, soda, fats, spicy, cigarettes, drugs, alcohol? Please explain: *
Do you overeat? If so, which foods and how often? *
Have you ever had to follow dietary restrictions? If so, how did you do with those restrictions? *
The most important thing I could do right now to improve my health is: *
Will family and/or friends be supportive of your decision to make healthy food and lifestyle changes? *
ADDITIONAL INFORMATION
Anything else you would like to share? *
ACKNOWLEDGEMENT
By placing my initials below, I acknowledge that any dietary, supplemental or lifestyle suggestions made by Tracey D. Abdul-Wahhab, CHC, CGFT are entirely recommendations and are not intended as the diagnosis, cure or treatment for any disease or ailment. I also acknowledge that my physician is my primary health care provider and is responsible for supervising all changes I make in diet, exercise and nutrient intake.
INITIAL and DATE *
A copy of your responses will be emailed to the address you provided.
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