Women's Health History

Personal Information * indicates required field.

First Name: *

Last Name: *

Email: *

Confirm Email: *

How often do you check e-mail:

Home Phone:

Mobile Phone:

Age:

Height:

Birthdate: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905

Place of Birth:

Current Weight:

Weight 6 months ago:

Weight one year ago:

Would you like your weight to be different?

If so, what?

Social Information

Relationship Status:

Where do you currenty live?

Children:

Pets:

Occupation:

Hours of work per week:

Health Information

Please list your main health concerns: *

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?

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?

Are your periods painful or symptomatic?

Have you reached, or are you approaching menopause?

Birth control history:

Do you experience yeast infections or urinary tract infections?

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 does your typical diet look like? 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:

Additional Comments

Anything else you would like to share?

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