Women’s Health Form – Jumpstart Session Bundle All of your information will remain confidential between you and the Health Coach. Name:* First Last Email:* How often do you check email?:Age:Height:Home Phone:Format: (###)###-####Work Phone:Format: (###)###-####Mobile phone:Format: (###)###-####Birth Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of birth:Current weight:Weight six months ago?:Weight one year ago?:Would you like your weight to be different?:If so, what?: Social InformationRelationship status:Where do you currently live?: Children:PetsOccupation:Hours of work per week:Health InformationPlease list your main health concerns: Other concerns and/or goals?: At what point in your life did you feel best?: Allergies or sensitivities? Please explain: Any serious illnesses/hospitalizations/injuries?: What blood type are you? Any pain, stiffness or swelling?: Constipation/Diarrhea/Gas?: How is/was the health of your mother?: How is/was the health of your father?: What is your ancestry? Are your periods regular?: How many days is your flow?: How frequent are your periods?: Are your periods 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 sleep? How many hours of sleep do you get per day?: Do you wake up at night?: Why do you wake up at night? Medical InformationDo you take any supplements or medications? Please list: Any healers, helpers or therapies with which you are involved? Please list: What role do sports and exercise play in your life?: Food InformationWhat foods did you eat often as a child?Breakfast Lunch Dinner Snacks Liquids What is your food like these days?Breakfast Lunch Dinner Snacks Liquids Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?: Do you cook? What percentage of your food is home-cooked?: Where do you get the rest from?: Do you crave sugar, coffee, cigarettes, or have any major addictions?: The most important thing I should do to improve my health is: Additional CommentsAnything else you would like to share?: Captcha NameThis field is for validation purposes and should be left unchanged.