Women's Health History
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First Name:
Last Name:
Email:
How Often Do You Check Email?
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Phone Number:
Work:
Age:
Height:
Birthdate:
JJ
/
MM
/
YYYY
Place of Birth:
Current Weight:
Weight Six Months Ago:
Weight One Year Ago:
Would You Like Your Weight to be Different?
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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/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?
How is your sleep?
How many hours?
What blood type are you?
Do you wake up at night?
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If yes, why?
Any pain, stiffness, or swelling?
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Constipation/Diarrhea/Gas?
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Allergies or sensitivities? Please explain:
Are your periods regular?
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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 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? (BREAKFAST)
What foods did you eat often as a child? (LUNCH)
What foods did you eat often as a child? (DINNER)
What foods did you eat often as a child? (SNACKS)
What foods did you eat often as a child? (LIQUIDS)
What is your food like these days? (BREAKFAST)
What is your food like these days? (LUNCH)
What is your food like these days? (DINNER)
What is your food like these days? (SNACKS)
What is your food like these days? (LIQUIDS)
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
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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?
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The most important thing I should do to improve my health is:
Anything else you would like to share?
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