Women’s Health History

Personal Information

First Name: *
Birthdate:
Last Name: *
Place of Birth:
Email: *
Height (inches):
Mobile Phone:
Current Weight (lbs.):
Home Phone:
Weight Six Months Ago (lbs.):
Country: *
Weight One Year Ago (lbs.):
State or Provence:
Would you like your weight to be different?:
City or Town:
If so, what? (lbs.):

Health Information

Please list your main health concerns:
Other concerns and/or goals?:
At what point in your life did you feel your 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 sleep a night?:
Do you wake up at night?:
Why do you wake up at night?:
What blood type are you?:
Constipation/Diarrhea/Gas?:
Any pain, stiffness or swelling?:
Allergies or sensitivities? Please explain:
Are your periods regular?:
How frequent?:
Length in days:
Painful or symptomatic? Please explain:
Do you experience yeast infections or urinary tract infections? Please explain:
Birth control history:
Reached or approaching menopause? 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?
What is your food like these days?
Breakfast:
Breakfast:
Lunch:
Lunch:
Dinner:
Dinner:
Snacks:
Snacks:
Liquids:
Liquids:

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
Do you cook?:
What percentage 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?:

Verification

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