Health History Form Women's Health History

Please complete the form below. All your information will remain confidential between you and your assigned Health Coach.

Once completed, this form will be submitted to: iamready@catalysthealthasia.com.


Personal Information
Given Name *
Family Name *
Email *
Average no. of hours spent per day online/with digital devices *
Phone Home
Work
Mobile
Age *
Height *
Date of Birth
Place of Birth *
Current Weight *
Weight 6 months ago
One year ago
Would you like your weight to be different? *
If so, what?
Social Information *
Relationship Status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week
How often do you travel for work?
/month on average
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/hospitalisations/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? *
Any pain, stiffness, or swelling? *
Constipation/Diarrhoea/Gas? *
Allergies or sensitivities? Please explain *
Women's Health
Are your periods regular? *
How many days is your flow? *
How frequent? *
Any pain or symptoms? 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?
The most important thing I should do to improve my health is
Food Information
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Beverages
 
What do your meals look like these days?
Breakfast
Lunch
Dinner
Snacks
Beverages
 
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? *
Additional Information
Anything else you would like to share?

By submitting this Form, you hereby agree that Catalyst Health Pte Ltd may collect, use, disclose personal data about you under the Personal Data Protection Notice.

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