Women's Health Form

WOMEN'S HEALTH FORM

Personal Information

First Name

Last Name

How often do you check your email?

Home Phone

Birthday

Current Weight

Work Phone

Mobile Phone

Place of birth

Weight 6 months ago

Weight 1 year ago

Would you like your weight to be different? If so, what?

Social Information

Relationship Status

Chlidren?

Current occupation?

Where do you currently live?

Pets?

How many hours per week do you work?

Health Information

Please list your main concerns

Other concerns/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 generally sleep?

Do you wake up at night?

If yes, why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

Are 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 or urinary tract infections? Please explain:

Medical Information

Do you take any medications? Please list here.

Any healers, helpers or therapies with which you are involved? Please list:

What role do sports and exersize play in your life?

Food Information

What foods did you eat often as a child?

Breakfast

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:

What is your food like these days?

Breakfast

Dinner

Snacks

Liquids

Additional Comments

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