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Women's Health History Form
Personal Information    
     
Name:   Age:
 
Address:   Height:
 
E-mail:   Birthdate:
 
How often do you check mail:   Place of birth:
 
Home Phone:   Current weight:
 
Work Phone:   Weight six months ago:
 
Cell Phone:   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:   What blood type are you?:
 
Other concerns and/or goals?:   Do you sleep well?:
 
At what point in your life did you feel best:   Do you wake up at night?:
 
Any serious illness/hospitalizations/injuries:   Why?:
 
How is/was the health of your mother?:   Any pain, stiffness or swelling?:
 
How is/was the health of your father?:   Constipation/Diarrhea/Gas?:
 
What is your ancestry?:   Allergies or sensitivities? Please explain:
 
   
     
Are your periods regular?:   Birth control history:
 
How frequent?:   Do you experience yeast infections or urinary tract infections? Please explain
 
Painful or symptomatic?:   Reaching or Approaching Menopause? Please explain:
 
Please explain:    
   
     
Medical Information    
     
Do you take any supplements or medications:   Any healers, helpers, pets or therapies with which you are involved?:
 
Please List:   Please List:
 
    What role do sports and exercise play in your life?:
   
     
Food Information:    
     
What foods did you eat often as a child?   What’s your food like these days?
     
Breakfast   Breakfast
 
Lunch   Lunch
 
Dinner   Dinner
 
Snacks   Snacks
 
Liquids   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?:    
   
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:
   
     
Aditional Comments    
     
Anything else you would like to share?: