Skip to content
Toggle Navigation
Home
1:1 Coaching
Recipes
Baking
Basics
Breakfast
Dessert
Dinner
Gluten-Free
Healing
Healthy Comfort Food
Hot Drinks
Lunch
Salads
Vegan
Blog
PCOS Quiz
Mentruation
Monthly Cycle
Contact
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
Share
Share
Share
Share
Mail
Share
Spread the love!
Home
1:1 Coaching
Recipes
▼
Baking
Basics
Breakfast
Dessert
Dinner
Gluten-Free
Healing
Healthy Comfort Food
Hot Drinks
Lunch
Salads
Vegan
Blog
▼
PCOS Quiz
Mentruation
Monthly Cycle
Contact