Holistic Approach to Women's Health, Weight Loss

In order for us to come up with a plan for you as an individual, it is important to start with a thorough health history. Before we meet for our initial consultation be sure to fill out the correct form below.

Revisit Form

All of your information will remain confidential between you and the Health Coach.

Personal Information

First Name(required)

Last Name(required)

Email address(required)

Health Information

What positive changes have you noticed since your last session?

What are your main concerns at this time?

Any changes with weight?

How is your sleep?

Constipation or diarrhea?

How is your mood?

Food Information

Are you cooking more?

Yes

What foods do you crave?

What is your diet like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Additional Comments

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Women’s Health History

Personal Information

First Name(required)

Last Name(required)

Email address(required)

How often do you check email?

Home Phone

Work Phone

Mobile Phone

Age

Height

Birthdate

Place of birth

Current Weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so, how?

Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Health Information

Please list your main health concerns

Other concerns and/or goals

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night

Why?

Any pain, stiffness or swelling?

Constipation/diarrhea/gas?

Allergies or sensitivities?

Are your periods regular?

How many days is you flow?

How frequent?

Painful or symptomatic?

Reached or approaching menopause?

Birth control history

Do your experience yeast infections or urinary tract infections?

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?

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family/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 Comments

Anything else you'd like to share?

This field should be left blank

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Men Health History

Personal Information

First Name(required)

Last Name(required)

Email address(required)

How often do you check email?

Home Phone

Work Phone

Mobile Phone

Age

Height

Birthdate

Place of birth

Current Weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so, how?

Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Health Information

Please list your main health concerns

Other concerns and/or goals

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night

Why?

Any pain, stiffness or swelling?

Constipation/diarrhea/gas?

Allergies or sensitivities?

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?

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family/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 Comments

Anything else you'd like to share?

This field should be left blank

Please wait...

Monhegan-Wellness

Health Forms

Revisit Form

Personal Information

Health Information

Food Information

What is your diet like these days?

Additional Comments

Personal Information

Social Information

Health Information

Medical Information

Food Information

Additional Comments

Personal Information

Social Information

Health Information

Medical Information

Food Information

Additional Comments