Women’s Health History Form

Name

Address

Email *

How often do you check email?

Work Phone #

Cell Phone #

Age

Height

Birthdate

Place of Birth

Current Weight

Weight 6 months ago

Weight 1 year ago

Relationship Status

Would you like your weight to be different? If so, what?

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 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 sleep?

Do you wake up at night? Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas? Please explain.

Allergies or Sensitivities? Please explain.

Are your periods regular?

How many days is your flow?

How frequent?

Birth Control History?

Painful or symptomatic? Please explain.

Reaching or approaching menopause? Please explain.

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 Breakfast, Lunch, Dinner, Liquids and Snacks

What's your food like these days? List Breakfast, Lunch, Dinner, Snacks, and Liquids.

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

What percentage of your food is home-cooked? Where do you get the rest from?

Do you cook?

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?

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