Women’s Health History Form

Name *

First

Last

Email *

Phone

How often do you check e-mail:

Age

Height

Birth Date

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:

How many hours do you work a 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/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?:

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? 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:

What is your food like these days? Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments

Anything else you would like to share?:

Signature *