Free Consultation -

Complimentary PCOS Consultation

Welcome! Please take some time to fill in the Health Questionnaire and I will get back to you via email ASAP to schedule a complimentary PCOS Consultation.

We will use the information you provide below as the base for our meeting. We will discuss your main health concerns and figure out if it would be beneficial for us to work together.

I can't wait to hear from you!
Love, Nadine

Personal Health History

Please share this valuable information with me, so I can best help you according to your needs. All information will remain confidential.

Personal Information
Name
First Last
Email
Enter Email Confirm Email
Phone
Age
Height
Date of birth
Place of birth
Current weight
Weight 6 months ago
Weight 1 year ago
Would you like your weight to be different?
If yes, what would you like to change?
Social Information
Relationship Status
Where do you currently live?
Children
Pets
Occupation
Hours per week
Health Information
PCOS Symptoms
- Infertiliy
- Lack of ovulation
- Irregular periods
- Absent periods
- Ovarian cysts
- Insulin resistance
- Difficulty loosing weight
- Acne
- Hairloss
- Unwanted hair growth, e.g on chin or breasts
- Mood swings/Depression
Please list your main health concerns.
Other concerns and/or goals?
Any serious illnesses/hospitalizations/injuries?
How is your sleep?
How many hours?
Do you wake up at night?
If so, why?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
Women's Health
Are your periods regular?
How many days is your flow?
How frequent?
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:
What role do sports and exercise play in your life?
Food Information
What foods did you eat often as a child?
Please give some examples of breakfast, lunch, dinner, snacks & drinks.
What is your food like these days?
Please give some examples of breakfast, lunch, dinner, snacks & drinks.
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 of your food from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
How is your relationship with food? (Mindset, disordered eating,...) Please explain:
The most important thing I should do to improve my health is:
In which coaching programs are you most interested?
- "My Happy Makeover" - A 90-Day Personal Coaching Program
- "My Happy Lifestyle" - A 6-Months Personal Coaching Program
- "My Happy Coaching Group" - A 3-Months Group Coaching Program
I will be in touch!
Thank you for taking the time to fill in the health history form. I will get back to you after 1 -2 working days. Please check all your inboxes, including the spam and promotional email folder. Don't hesitate to contact me if you don't receive anything. Please tick the box below when you have read this. Thanks.
- I will check all my inboxes
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Free Consultation

Complimentary PCOS Consultation

Personal Health History

Personal Information

Social Information

Health Information

Women's Health

Medical Information

Food Information

I will be in touch!

CONTACT ME

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