Health History

Name:
Email:
Phone:
Age:
Height:
Birthdate:
Birthplace:
Current weight:
Weight six months ago:
Would you like your
weight to be different?
yesnonot sure
If so, what?
Relationship status:
Where do you
currently live?
Children and their ages:
Pets:
Occupation:
Hours of work per week:
Please list your main health
concerns and health goals:
Any serious illnesses/
hospitalizations/injuries?
How is/was the health
of your mother?
How is/was the health
of your father?
What blood type are you?
How is your sleep? Hours?
Any pain, stiffness,
or swelling?Describe
Constipation/Diarrhea/Gas?
Allergies or sensitivities?
Please explain:
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
Please explain:
Reached or approaching
menopause? Please explain:
Birth control history:
Do you experience yeast
or urinary tract infections?
Please explain:
Do you take any supplements
or medications? Please list:
What role do sports and
exercise play in your life?
What foods did you
eat often as a child?
What is your food
like these days?
Who will be supportive
of you to make food and/or
lifestyle changes?
Do you Cook?
What percentage of your
food is home-cooked?
Do you crave sugar,
coffee, cigarettes, or have
any major addictions?
The most important
thing I should do to
improve my health is:
Anything else you'd
like to add?

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About Healthy Beach Girl

Throughout my journey in this lifetime, I have had many identities including Professional Mechanical Engineer, Merchant Marine Officer, Naval Officer, Collegiate Athlete, Swim Coach, Windsurfing Instructor, Fitness instructor, Daughter, Sister, and most importantly Mom and Wife. All of those things are just things I DO, but they are not who I AM.  Many of us have asked the question “Who am I and what am I here on Earth to do?” Read More