Health Discovery Inventory – Woman

It’s all about YOU!

I want to thank you for taking time to complete this Health Discovery Inventory. It is designed to collect a LOT of information as together we learn how to help support your efforts to optimize your health goals. Please be as thorough as possible with your answers so we have a really clear picture of your past and present.

Once complete, please click on the Save and Send button and I will receive it and look everything over promptly. I look forward to learning more about you and how I can help you look and feel your best now and for all the years to come!

Health Discovery Assessment - Women's

Name
Email
How often do you check emails daily?
Best phone number:
Birth Date
Place of Birth:
What is your current height?
What is your current weight?
What was your weight six months ago?
What was your weight one year ago?
How would you like your weight to be different?

Social Information

What is your relationship status?
Do/did you have children?
Do you feel safe at home?
What type of pets do you have?
Where do you currently live?
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Please describe your occupation and the tasks you perform.
How many hours do you work weekly>
Please describe how you spend your days currently.
How often do you get together with friends or family?
Please share the types of social activities you are involved with:

Health Information

Please list your main health concerns:
Other concerns and/or goals?
How often do you exercise weekly?
30 minutes1 hour2 hours3 hours4+ hoursI rarely have time to exercise.
Please describe the types of physical activities you are involved in weekly:
What role do sports and exercise play in your life? Why or why not?
At what point in your life did you feel best? Why?
Any serious hospitalizations, illnesses, or injuries?
What types of chemicals have you been exposed to?
Describe the health of your mother?
Describe the health of your father?
Describe the health of your siblings?
Were you breast fed as an infant?
In what way were you delivered?
Were there any complication during your birth? Please explain.
What is your ancestry?
What is your blood type?
A +/-B +/-0 +/-A/B
Describe how well you sleep?
How many hours a night do you sleep on average?
Do you wake up at night? Why?
Please list any pain, stiffness, or swelling:
How often do you experience constipation, diarrhea or gas?
Please explain any allergies or sensitivities:

Women's Health

Describe your periods when you were younger:
How are your periods as an adult?
How many days do you flow?
How frequently?
Please explain if painful or symptomatic:
Reached or approaching menopause? Please explain:
What is your birth control history?
Do you experience yeast infections or urinary tract infections? Please explain:

Medical Information

Please list any supplements or medications you are curretnly taking:
Please list any healers, helpers, or therapies with which you are involved:

Food Consumption

What breakfast foods did you eat often as a child? Please be as specific as possible.
What lunch foods did you eat often as a child? Please be as specific as possible.
What dinner foods did you eat often as a child? Please be as specific as possible.
What snack foods and liquids did you eat/drink often as a child? Please be as specific as possible.
What breakfast foods do you eat now? Please be as specific as possible.
What lunch foods do you eat now? Please be as specific as possible.
What dinner foods do you eat now? Please be as specific as possible.
What snacks foods and liquids do you eat/drink now? Please be as specific as possible.
Please describe your cravings and the types of foods you crave: Please be as specific as possible.
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? How so?
Do you cook?
What percentage of your food would you say is home-cooked?
Please explain where you get the rest of your food from? Be specific.
Do you crave sugar, coffee, salt, crunchy things, dairy, breads, cigarettes, or have any major addictions? How often?
How much coffee do you consume daily? Please explain what you usually add to your coffee.
The most important thing I should do to improve my health is:
How committed are you to getting your optimum health back?
Please describe why you decided to consider working with a Wellness Coach.
How did you learn about me?

Additional Comments

Is there anything else you would like to share with me? Be as detailed as you would like.
Thank you for taking the time to provide so much information. I know it was a lot!

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Health Discovery Inventory – Woman

It’s all about YOU!

Health Discovery Assessment - Women's

Social Information

Health Information

Women's Health

Medical Information

Food Consumption

Additional Comments

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