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Women's Health History Form
Name
Address
E-mail Address
How often do you check your email
Home Phone() -
Work Phone() -
Cell Phone() -
Age
Height
Birthdate
Place of Birth
Current Weight
Weight six months ago
Wright one year ago
Would you like your weigh to be different
If so, what?
Relationship Status
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 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?:
Painful or symptomatic?:
Please explain:
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?:
What role do sports and exercise play in your life?:
What foods did you eat often as a child? Breakfast
Lunch
Dinner
Snacks
Liquids
What’s your food like these days? 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?:
What percentage is not?:
Where do you get the rest from?:
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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