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WOMEN HEALTH HISTORY FORM
All of your information will remain confidential between you and the Health Coach.
PERSONAL:
Would you like your weight to be different?
yes
no
maybe
SOCIAL: Relationship Status
GENERAL HEALTH
WOMAN'S HEALTH
Are your periods regular?
Yes
No
Sometimes
MEDICAL
FOOD
Do you cook?
Yes
No
Sometimes
ADDITIONAL COMMENTS
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