Women’s Health History Form PERSONAL INFORMATIONName First Last Email How often do you check email? Home PhoneWork PhoneMobile PhoneAge Height Birth Date MM slash DD slash YYYY Place of Birth Current Weigth Weight 6 Months Ago Weight 1 Year ago Would 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
