WOMEN'S HEALTH FORM

Welcome to ECOPIA! Thank you for choosing to invest in your Health & Wellness, we’re confident our programme will be one of your greatest decisions. Please complete the form below in order to help us gain a better understanding of you and your current situation in order to create a bespoke plan, tailored to your individual needs and goals. We can’t wait to begin with you on your Health & Wellness journey.

*All of your information will remain confidential between you and your Health & Wellness Coach.

Personal Information

First Name

Last Name

How often do you check e-mail?

Home Phone:

Mobile Phone:

Work Phone:

Age:

Height:

Birthdate:

Current weight:

One year ago:

Place of Birth:

Weight six months ago:

Would you like your weight to be different?

If you’d like your weight to be different, what would you like it to be?

Social Information

Relationship status:

Children:

Occupation:

Where do you currently live?

Pets:

Hours of work per week:

Health Information

Please list your main health concerns:

At what point in your life did you feel your best?

Any other concerns or goals?

Any serious illnesses, hospitalisations or injuries?

How is/was the health of your mother?

What is your ancestry?

How is the quality of your sleep?

Do you wake up at night?

Any pain, stiffness or swelling?

Any allergies or sensitivities? If so, please explain:

How many days is your flow?

How is/was the health of your father?

What blood type are you?

On average, how many hours do you sleep each night?

What causes you to wake at night?

Any constipation, diarrhoea or gas?

Are your periods regular?

How frequent is your flow?

Is it painful or symptomatic? If so, please explain:

Have you reached or approaching menopause? If so, please explain:

What is your birth control history?

Do you experience yeast infections or urinary tract infections? If so, please explain:

Medical Information

Do you take any supplements or medications? If so, please list:

Are you involved with any healers, helpers or therapies? If so, please list:

What role do sports and excercise play in your life?

Food Information

Breakfast:

Dinner:

Lunch:

Snacks:

Liquids:

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

Where do you get the rest of your food from?

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:

What is your diet like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments

Anything else you'd like to share?

Would you like your sessions in English or German?

Print your name

Your Signature

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What foods did you eat often as a child?