Health History

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This information is confidential and is used only to design and supervise your program. See our Privacy Policy. Muscle Mommy Coaching is not a HIPAA covered entity but treats your health information as confidential.

Menopause staging

Date of last period

Cycle status

Regular Irregular Stopped 12+ months ago N/A — hysterectomy

Have you had a hysterectomy?

Yes No

Year of hysterectomy

Were your ovaries removed?

Yes No Partially Unsure

Are you on hormone therapy (HRT)?

Yes No

HRT type

Prescribing physician

Symptoms you experience

Hot flashes Night sweats Sleep disruption Mood changes Brain fog Joint pain Vaginal dryness Low libido Weight redistribution Fatigue

Pelvic floor

These questions determine your starting loads. Please answer honestly — nothing here disqualifies you from training.

Do you leak with exertion?

Yes No

Do you feel pelvic heaviness or pressure?

Yes No

Have you been diagnosed with prolapse?

Yes No

Have you had prior pelvic floor physical therapy?

Yes No

When did you have pelvic floor PT?

Number of vaginal births

Number of C-sections

Diastasis recti?

Yes No Don't know

If you have pelvic floor symptoms, we recommend you also see a pelvic floor PT.

Bone health

Have you had a DEXA scan?

Yes No

Year of most recent DEXA

DEXA result

Normal Osteopenia Osteoporosis Don't know

Have you had a fracture as an adult?

Yes No

Fracture details

Family history of osteoporosis?

Yes No Don't know

Medical

Current diagnoses

Medications and supplements

Surgeries

Conditions

High blood pressure High cholesterol Diabetes or prediabetes Thyroid condition Heart disease Stroke Asthma Autoimmune condition Cancer None of these

Has a physician restricted your exercise?

Yes No

Restriction details

Do you experience chest pain, unusual shortness of breath, or dizziness with exertion?

Yes No

Injury, training, lifestyle

Current pain

Past injuries

Painful movements

Lifting experience

Never A little Regularly in the past Currently

Current activity

Days active per week

Hours in bed per night

Sleep quality (1–10): 5

Daily steps (optional)

Stress level (1–10): 5

Alcoholic drinks per week

Nutrition and final

Protein sources

Allergies and intolerances

Dietary pattern

None Vegetarian Vegan Pescatarian Gluten-free Other

Do you eat breakfast?

Yes No

Do you train fasted?

Yes No

Is there anything about your history with food, your body, or exercise that would help me coach you better? You can skip this. If you answer it, it stays between us.

Everything above is accurate to the best of my knowledge. I will notify Muscle Mommy Coaching of any change.

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Signature date

Menopause staging

Pelvic floor

Bone health

Medical

Injury, training, lifestyle

Nutrition and final