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Women’s Form

All of your information will remain confidential between you and the Health Coach.

"*" indicates required fields

Personal Information

Name*

First Last

Email*

How often do you check e-mail:

Best Phone Number To Contact you*

Birthday*

Month

Day

Year

Age*

Place of Birth*

Height*

Current Weight*

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different?*

Yes

No

If Yes, What would you like different?

Social Information

Relationship Status*

Where do you currently Live?*

Children?*

Yes

No

Pets?

Yes

No

Occupation*

How Many Hours a Week?*

Please enter a number from 0 to 100.

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/hospitalizations/injuries?:*

How is/was the health of your mother?:*

How is/was the health of your father?:*

What blood type are you?:*

What is your ancestry?:*

How many hours of sleep do you get?:*

How is your sleep?:*

Do you wake up at night?:*

Constipation/Diarrhea/Gas?:*

Yes

No

Any pain, stiffness or swelling?:*

Yes

No

Allergies or sensitivities?*

Are your periods regular?:*

No

Yes

Does not apply

How many days is your flow?:

How frequent?:

Infrequent

Often

Uncomfortable

Excessive

Painful or symptomatic period?*

Yes

No

If Yes, Explain:

Reached or approaching menopause?*

Yes

No

Birth control history:*

Do you experience yeast infections or urinary tract infections?*

Do you take any supplements or medications?*

Any healers, helpers or therapies with which you are involved?*

What role do sports and exercise play in your life?:*

Food Information

What foods did you eat often as a child?

Breakfast*

Lunch*

Dinner*

Snacks*

Liquids*

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

Yes

No

Unsure

Do you cook?:*

Yes

No

What percentage of your food is home-cooked?:*

100%

75%

50%

25%

Other

Where do you get the rest from?:

Do you crave sugar, coffee, cigarettes, or have any major addictions?:*

No

Sugar

Tabacco

Coffee

Alcohol

Other

If Other please describe.

The most important thing about my health I want to improve is?*

What is your food like these days?

Breakfast*

Lunch*

Dinner*

Snacks*

Additional Comments

Anything else you would like to share?:

Email

This field is for validation purposes and should be left unchanged.

Goji Fitness LLC

Health, fitness and nutrition coaching company with an emphasis on bio-individuality.

We're in the business of inspiring transformation in our clientele. We believe that our clients can heal themselves by themselves and have all it takes inside of them (wisdom, intuition, courage, innate knowledge of what works for them) to create the health and life of their dreams. Our coaching focuses on guiding our clients to decipher their body's language, getting to the root cause beyond symptoms and helping them feel more confident to take consistent action.

Email us

Courses & Services

We equip you with knowledge, tools and support to create bio-individual detox and get-to-know your own body experiences.

Live Class Schedule
On Demand Library
Tantric Date Night
Individual Health Coaching
Small Group Health Coaching Program
Personal Training
Feeding Succcess Book

Zenberry Mix

We also make the world's best-tasting superfood protein smoothie: Zenberry. Pick up some at Zenberrymix.com