Women's Health History Form

Your information is always kept confidential.

Name

First Name

Last Name

Email address

How often do you check email?

Home phone

(###)

###

####

Cell phone

(###)

###

####

Work phone

(###)

###

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Age

Birthdate

YYYY

Birthplace

Height

Current weight

Weight six months ago

Weight one year ago

Would you like your weight to be different? Please explain.

Relationship status

Where do you currently live?

Number of children

Pets

Occupation

Hours of work per week.

Please list your main health concerns.

Do you have other concerns or goals?

At what point in your life did you feel best?

Any serious illnesses, injuries, or hospitalizations?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What is your blood type?

How is your sleep? How many hours each night?

Do you wake up at night? Please explain.

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas?

Do you have any allergies or sensitivities? Please explain.

Are your periods regular? How many days of flow? How frequent?

Are your periods painful or symptomatic? Please explain.

Have you reached or are approaching menopause? Please explain.

What is your birth control history?

Do you experience yeast infections or urinary tract infections? Please explain.

Please list any supplements or medications you currently take.

Please list any healers, helpers, or therapies with which you are currently involved.

What role do sports and exercise play in your life?

What foods did you eat often as a child for breakfast?

What foods did you eat often as a child for lunch?

What foods did you eat often as a child for dinner?

What foods did you eat often as a child for snacks?

What liquids did you consume often as a child?

What foods do you eat often for breakfast now?

What foods do you eat often for lunch now?

What foods do you eat often for dinner now?

What foods do you eat often for snacks now?

What liquids do you consume often now?

Will your 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:

Anything else you would like to share?