Women’s Health Form – NutriLife 101

Please fill in this form before your first session so we can make the most of our time together. Fields marked * are required.

First Name *

Last Name *

Email Address *

How often do you check e-mail *

Home Phone

Work Phone

Mobile Phone

Age

Height

Date of birth

Birth Place

Current Weight

Weight Six Month Ago

Weight One year Ago

Would you like your weight to be different

If so what?

Social Information

Relationship Status

Where do you currently live?

Children

Occupation

Pets

Hour of work per week

Health Information

Please list your main health concerns

Other concerns and/or Goals?

At what point of 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 you are?

How is your sleep?

How many hour?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain

Are your periods regular?

How frequent?

How many days is your flow?

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

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

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

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Additional Comments

Anything else you would like to share?