Women's Confidential Health History
Full Name
First Name
Last Name
E-mail Address
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Contact Number
Address
Street Address
Street Address Line 2
City
County
Post Code
Date of Birth
Please select a day
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Day
Please select a month
January
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April
May
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July
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September
October
November
December
Month
Please select a year
2024
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Year
Has your doctor ever said your blood pressure was too high or too low?
Yes
No
Please provide details.
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?
Yes
No
Please provide details.
Has your doctor ever told you that your cholesterol was too high?
Yes
No
Please provide details.
Have you (or a family member) ever been told that you have diabetes?
Yes
No
Please provide details.
Do you have any injuries or orthopedic problems (back, knees, etc)?
Yes
No
Please provide details.
Do you have stiff or swollen joints?
Yes
No
Please provide details.
Do you have tension or soreness in any area?
Yes
No
Please provide details.
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Current Weight:
Weight Six Months Ago:
Weight One Year Ago:
Would you like your weight to be different?
Yes
No
If yes, what is your ideal weight?
Relationship Status:
Married
Divorced
Separated
Widowed
Other
Children:
Grandchildren:
Pets:
Occupation:
Hours Per Week:
Please list your main health concerns:
Other health concerns and/or goals:
At what point in your life did you feel best?
Any serious illnesses, hospitalizations, or 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?
Yes
No
Sometimes
How many hours per night?
Do you wake up during the night?
Yes
No
Sometimes
If yes, why?
Do you experience yeast infections or urinary tract infections? Please explain:
Constipation/Diarrhea/Gas? Please explain:
Allergies or sensitivities? Please explain:
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved? Please list
What role does sports and exercise play in your life?
What foods did you eat often as a child? Breakfast, Lunch, Dinner, Snacks, Beverages:
What's your food like these days? Breakfast, Lunch, Dinner, Snacks, Beverages:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
I don't know
Some will, some won't
What percentage of your food is home cooked?
Do you cook?
Where do you get the rest of your food 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 want to share?
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