Personal Health History Form -

Complimentary PCOS Consultation

Apply now by filling out the form below

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
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 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:
Which of my programs (if any) would you be most interested in?
- "My Happy Coaching Session" - Individual Coaching Sessions
- "My Happy Makeover" - A 90-Day Personal Coaching Program
- "My Happy Lifestyle" - A 6-Months Personal Coaching Program
Discount Code

Personal Health History Form

Complimentary PCOS Consultation

Personal Health History

Personal Information

Social Information

Health Information

Women's Health

Medical Information

Food Information