women's health history

Name

First Name

Last Name

Email Address

How often do you check e-mail?

Home Phone

(###)

###

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Work Phone

(###)

###

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Mobile Phone

(###)

###

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Age:

Height:

Birthdate:

YYYY

Place of Birth:

Current Weight:

Weight (6 months ago):

Weight (1 year ago):

Would you like your weight to be different?:

If so, what?

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:

Other concerns and/or goals?:

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

Any serious illnesses/hospitalization/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?:

Why?

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:

Medical Information

Do you take any supplements or medications? Please list:

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

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

Food Information

What foods did you eat often as a child? What is 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 do to improve my health is:

Additional comments

Anything else you like to share?: