Women's Health History

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Name *

First

Last

Email *

How often do you check email? *

Home Phone *

Work Phone *

Mobile Phone *

Age *

Height *

Birth (month/day/year) *

Place of birth: *

Current Weight: *

Weight six month ago: *

One year ago: *

Would you like your weight to be different? *

If so what? *

Relationship status: *

Where do you currently live? *

Children: *

Pets: *

Occupation: *

Hours of work per week: *

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 is your ancestry? *

What blood type are you? *

How is your sleep? *

How many hours? *

Do you wake up at night? *

Do you wake up at night?

Any pain, stiffness or swelling? *

Constipation/Diarrhea/Gas? *

Allergies or sensitivities? Please Explain: *

Are your periods regular? *

How many days is your flow? *

How frequent? *

Painful or symptomatic? Please explain: *

Reached or approaching menopause? Please Explain: *

Birth control history: *

Do you experience yeast infections or urinary tract infections? Please explain: *

Do you take any supplements or medications? Please list: *

Any healers, helpers or therapies with whih you are involved? Please list: *

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

What foods did you eat often as a child?

Breakfast, Lunch, Dinner, Snacks and 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 do to improve my health is: *

What is your food like these days?

Breakfast, Lunch, Dinner, Snacks and Liquids

Anything else you would like to share?

Women's Health History

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