Women’s Health History

Personal Information

Name(required)
Address
Email(valid email required)
Home Phone
Work Phone
Cell Phone
Age
Height
Birthdate
Current weight
Weight six months ago
Would you like your weight to be different?
If so, what?

Social Information

Relationship Status
Children?
Occupation
Hours of work per week

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 illness/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
Are your periods regular?
How may days is your flow?
How frequent?
Painful or symptomatic?
Please explain
What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night?
Why?
Any pain, stiffness or swelling?
Constipation/Diarrhea/ Gas? Please explain
Allergies or sensitivities? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
Reaching or Approaching Menopause? Please explain

Medical Information

Do you take any supplements or medications?
Please List
What role does exercise play in your life?
Any healers, helpers, pets or therapies with which you are involved?
Please List

Food Information

What's your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should change about my diet to improve my health is

Additional Comments

Anything else you would like to share?
How did you hear of me?

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