Women’s Health History Form

PERSONAL INFORMATION

Name


Address


Email

How often do you check mail?

Home Phone

Work Phone

Cell Phone

Age

Height

Birthdate

Place of Birth

Current Weight

Weight six months ago

Weight one year ago

Would you like your weight to be different?

If so, what?


SOCIAL INFORMATION

Relationship status

Children?

Pets?

Occupation

Hours of work per week


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 illness/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?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?


Constipation/Diarrhea/Gas? Please explain:


Allergies or sensitivities? Please explain:


Are your periods regular?

How many days in your flow?

How frequent?

Painful or symptomatic? Please explain:


Reaching or approaching menopause? Please explain:


Birth control history:


Do you experience yeast infections or urinary tract infections? Please explain:




MEDICAL INFORMATION

Do you take any supplements or medications?


Please list:


Any healers, helpers, pets 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?

Breakfast:


Lunch:


Dinner:


Snacks:


Liquids:


What's 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?

What percentage is not?

Where do you get the rest 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:



ADDITIONAL COMMENTS

Anything else you would like to share?