Woman’s Health History
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Personal
Name
(Required)
First
Last
Age
Height
Date of Birth
MM slash DD slash YYYY
Place of Birth
Email
(Required)
How often do you check your email?
Home Phone
Work Phone
Mobile Phone
Weight Six Months Ago
Current Weight
Weight Six Year Ago
Would you like your weight to be different?
If so, how?
SOCIAL
Relationship Status
Where do you live?
Any pets?
Occupation
How many hours do you work per week?
GENERAL HEALTH
What are your main health concerns?
Any other concerns and/or goals?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is/was your mother’s health?
How is/was your father’s health?
What is your ancestry?
What is your blood type?
How is your sleep?
How many hours do you sleep per night?
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any constipation, diarrhea, or gas?
Any allergies or sensitivities?
WOMEN’S HEALTH
Are your periods regular?
How many days is your flow?
How frequent?
Are your periods painful or symptomatic? If so, please explain:
Have you reached or are you approaching menopause? If so, please explain:
What is your birth control history?
Do you experience yeast infections or urinary tract infections? If so, please explain:
MEDICAL
List all supplements or medications:
Are you involved with any healers, helpers, or therapies?
What role do sports and exercise play in your life?
FOOD
Will your family and 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 does your non-home-cooked food come from?
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
Add
Remove
What foods do you typically eat these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Add
Remove
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
ADDITIONAL COMMENTS
Is there anything else you would like to share?
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