WOMEN’S HEALTH FORM

Personal Information

Print your full name(required)

Email(required)

How often do you check e-mail:

Home Phone:

Mobile Phone:(required)

Age:(required)

Height:

Birthdate (month/date/year):(required)

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?:

If so, what?:

Why did you come for this health history? (required)

Social Information

Relationship status:

Where do you currently live?:

Children:

Pets:

Occupation:

Hours of work per week:

Health Information

Please list your main health concerns:(required)

Other concerns and/or goals?:(required)

At what point in your life did you feel best?:(required)

Any serious illnesses/hospitalizations/injuries?:(required)

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?:(required)

How many hours?:(required)

Do you wake up at night?:(required)

Why?:

Any pain, stiffness or swelling?:(required)

Constipation/Diarrhea/Gas?:(required)

Allergies or sensitivities? Please explain:(required)

Women’s Health

Are your periods regular?:(required)

How many days is your flow?:

How frequent?:

Painful or symptomatic? Please explain:

Reached or approaching menopause? Please explain:

Birth control history:(required)

Do you experience yeast infections or urinary tract infections? Please explain:(required)

Medical Information

Do you take any supplements or medications? Please list:(required)

Any healers, helpers or therapies with which you are involved? Please list:(required)

What role do sports and exercise play in your life?:(required)

Food Information – History

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?: (required)

Do you cook?:(required)

What percentage of your food is home-cooked?:(required)

Where do you get the rest from?:(required)

Do you crave sugar, coffee, cigarettes, or have any major addictions?:(required)

The most important thing I should do to improve my health is:(required)

Food Information – Present

What is your food like these days?