WOMEN’S HEALTH HISTORY

Please write or print clearly. Your information will remain confidential between you and your Health Coach.

PERSONAL

First Name: Saria

Last Name: El Osman

Age: 40 Height: 170 Date of Birth: 7 january Place of Birth: Beirut

Email: saria.osman@ul.edu.lb How often do you check your email? M-F

Home Phone: Work Phone: Mobile Phone: 03215177

Current Weight: 70 Weight Six Months Ago: 65 Weight One Year Ago: 60

Would you like your weight to be different? yes If so, how? 60

SOCIAL

Relationship Status: Single

Where do you live? Amchit-Byblos

Any children? Any pets? 1 cat and 1 parrot

Occupation: University professor How many hours do you work per week? 25

GENERAL HEALTH

What are your main health concerns? Healthy lifestyle and Weight loss

Any other concerns and/or goals? Maintain youthful look and energy

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

Page 1
Danielle Daou
Lifestyle & Nutrition Health Coach
yourhealthmatterswithdd@gmail.com
+961 70 318 218
WOMEN’S HEALTH HISTORY
Any current or previous serious illnesses, hospitalizations, or injuries? None. thanks God

How is/was your mother’s health? Hypertension and diabetes (breast cancer 10 years ago)

How is/was your father’s health? Hypertension and diabetes (he had an accident 10 months ago and is still in
Coma now)

What is your ancestry? Lebanese What is your blood type? B+

GENERAL HEALTH (continued)

How is your sleep? good How many hours do you sleep per night? 6

Do you wake up during the night? If so, why? no

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas? Constipation and gas mostly

Any allergies or sensitivities? Gluten sensitivity

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WOMEN’S HEALTH

Are your periods regular? _No How many days is your flow? 4 How frequent? depends

Are your periods painful or symptomatic? If so, please explain:

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

What is your birth control history? Not married

Do you experience yeast infections or urinary tract infections? If so, please explain: No

MEDICAL

List all supplements or medications: vitamin D and omega 3

Are you involved with any healers, helpers, or therapies?

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Danielle Daou
Lifestyle & Nutrition Health Coach
yourhealthmatterswithdd@gmail.com
+961 70 318 218
WOMEN’S HEALTH HISTORY

What role do sports and exercise play in your life? I used to exercise regularly but have stopped a year ago

FOOD

Will your family and friends be supportive of your desire to make food and/or lifestyle changes? No

Do you cook? No What percentage of your food is home-cooked? 70

Where does your non-home-cooked food come from? delivery

What foods did you eat often as a child?

Breakfast Lunch Dinner Snacks Liquids

Corn flakes and milk Pasta hotdogsChips and pepsi

panckakes Burgers French fries candies and pepsi

Croissant Pizza sandwiches Chocolate and oepsi

What foods do you typically eat these days?

Breakfast Lunch Dinner Snacks Liquids

Boiled egg mjadra salad and fish daily dark chocolate and diet Pepsi

Oatmeal/fruits rice and stew chicken/veggiesnuts and diet seven up

mman2oush kafta and tabouli Hummus tahine fruits and juices

Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions? Sugar

Page 3
Danielle Daou
Lifestyle & Nutrition Health Coach
yourhealthmatterswithdd@gmail.com
+961 70 318 218
WOMEN’S HEALTH HISTORY
What is the most important thing you should change about your diet to improve your health? Stop binge eating, return to
Gym once lockdowns are over

ADDITIONAL COMMENTS

Is there anything else you would like to share?

Page 4
Danielle Daou
Lifestyle & Nutrition Health Coach
yourhealthmatterswithdd@gmail.com
+961 70 318 218