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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 *
Your answer
Email *
Your answer
How often do you check your email? *
Phone: home/work/mobile *
Your answer
Age *
Your answer
Height *
Your answer
Birthdate *
Your answer
Place of Birth *
Your answer
Current Weight *
Your answer
Desired Weight *
Your answer
Lowest Weight *
Your answer
Highest Weight *
Your answer
Why did you choose to come for a health consult? *
Your answer
SOCIAL INFORMATION
Relationship Status *
Your answer
Where do you currently live? *
Your answer
Children/Age/Gender *
Your answer
Pets *
Your answer
Occupation *
Your answer
Hours of work per week *
Your answer
HEALTH INFORMATION
Please list your main health concerns. *
Your answer
Other concerns and/or goals *
Your answer
At what point in your life did you feel your best? Please explain. *
Your answer
Are you currently pregnant? If yes, when is your due date? *
Your answer
Are you trying to conceive? *
Your answer
Are you breastfeeding? *
Your answer
Any serious illnesses/hospitalizations/injuries? *
Your answer
How is/was the health of your mother? *
Your answer
How is/was the health of your father? *
Your answer
Where do your parents and grandparents come from? *
Your answer
How is your sleep? *
Your answer
How many hours do you sleep? *
Your answer
Do you wake up at night? Why? *
Your answer
Do you suffer from constipation/diarrhea/gas? If so, how often? *
Your answer
Do you have any allergies or food sensitivities? Please explain. *
Your answer
WOMEN'S HEALTH
Are your periods regular? *
Your answer
How many days is your flow? *
Your answer
How frequent is your period? *
Your answer
Painful or symptomatic? Please explain: *
Your answer
Reached or approaching menopause? Please explain: *
Your answer
Birth control history: *
Your answer
Do you experience yeast infections or urinary tract infections? Please explain: *
Your answer
How is your energy level? *
Enjoyment of Life? *
Daily Stress Level? *
MEDICAL INFORMATION
Do you take any supplements, vitamins or medications? Please explain: *
Your answer
Do you have any healers, helpers, therapists or pets? Please list: *
Your answer
What role does exercise, sports and activities play in your life? *
Your answer
FOOD INFORMATION
What foods did you eat often as a child? Beverages? Snacks? *
Your answer
What is your food like these days? Beverages? Snacks? *
Your answer
What percentage of your food is home-cooked? *
Your answer
Where do you get the rest of your food? *
Your answer
Do you enjoy food? *
Your answer
Do you crave sugar, salt, coffee, bread, pasta, candy, sour, chocolate, meat, soda, fats, spicy, cigarettes, drugs, alcohol? Please explain: *
Your answer
Do you overeat? If so, which foods and how often? *
Your answer
Have you ever had to follow dietary restrictions? If so, how did you do with those restrictions? *
Your answer
The most important thing I could do right now to improve my health is: *
Your answer
Will family and/or friends be supportive of your decision to make healthy food and lifestyle changes? *
Your answer
ADDITIONAL INFORMATION
Anything else you would like to share? *
Your answer
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 *
Your answer
A copy of your responses will be emailed to the address you provided.
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