Women’s Health History Form Name * First Name Last Name Email * How often do you check your email: * Cell Phone * (###) ### #### Work Phone * (###) ### #### Age * Birthday * MM DD YYYY Place of Birth * Height * Current Weight * Weight 6 months ago * Weight 1 year ago * What would you like your weight to be? * Relationship Status: * Pets * Hours of work per week? * Children * Occupation * 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? * What blood type are you? Do you sleep well? How many hours? * Do you wake up at night? If so, why? * Any pain, stiffness, or swelling? * Constipation/Diarrhea/Gas? * Allergies or sensitivities? Please explain: * Are your periods regular? * Painful or symptomatic? Please explain: * How many days is your flow? How frequent? * Reaching 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, pets or therapies with which you are involved? Please list: * What role do sports and exercise play in your life? * What foods did you eat often as a child? * List your breakfast, lunch, dinner, snacks, and liquids What's your food like these days? * List your breakfast, lunch, dinner, snacks, and liquids Do you cook? What percentage of your food is home cooked? What percentage is not? Where do you get the rest from? * Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? * 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: * Anything else you would like to share? Thank you!
