Women’s Health History
PERSONAL INFORMATION
Name
First Name
Last Name
Email
example@example.com
How often do you check email?
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
Age
Height
Birthdate
Place of Birth
Current Weight
Weight six months ago
One Year ago
Would you like your weight to be different?
If so, what?
SOCIAL INFORMATION
Relationship Status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week
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HEALTH INFORMATION
Please 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?
How is your sleep?
How many hours?
Do you wake up at night?
Why?
Any pain, stiffness, or swelling?
How many bowel movements do you have per day?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Explain please
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WOMEN'S HEALTH
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain:
Reached or approaching menopause? Explain please:
Birth control history:
Do you experience yeast infections or urinary tract infections? Explain please:
MEDICAL INFORMATION
Do you take any supplements or medications? List please:
Any healers, helpers, or therapies with which you are involved? List please:
What role do sports and exercise play in your life?
FOOD INFORMATION
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
1
2
3
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
1
2
3
What is food to you?
Do your food choices support your happiness?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
What percentage of your food is made at home?
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 INFORMATION
On a scale of 1-10 how serious are you about changing your health & your life.
1
2
3
4
5
6
7
8
9
10
Anything else you would like to share?
Submit
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