Women’s Health History Form PERSONAL INFORMATIONName First Last Email How often do you check email?Home PhoneWork PhoneMobile PhoneAgeHeightBirth Date MM slash DD slash YYYY Place of BirthCurrent WeigthWeight 6 Months AgoWeight 1 Year agoWould you like your weight to be different?If so, what?SOCIAL INFORMATIONRelationship status:Where do you currently live?Children:Pets:Occupation:Hours of work per week:HEALTH INFORMATIONPlease 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?if so, Why?Any pain, stiffness, or swelling?Constipation/Diarrhea/Gas?Allergies or sensitivities? Please explain:WOMEN’S HEALTHAre 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 INFORMATIONDo 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 INFORMATIONWhat foods did you eat often as a child? Breakfast:Lunch:Dinner:Sacks:Liquids:What is 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?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 COMMENTSAnything else you would like to share?CAPTCHA
