Women’s Health History

Personal Information


Your Name (required):

Your Email (required):

Phone Number:

Health Information


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 Would It Be:

Relationship Status:

Children:

Pets:

Occupation:

Hours Of Work Per Week:

Please List Your Main Health Concerns:

Other Health Concerns


At What Point In Your Life Did You Feel Best?

Any Serious Illness, Hospitalization or Injuries?

How Is The Health Of Your Mother?

How Is 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?

If So, Why?

Any Pain Stiffness Or Swelling?

Constipation, Diarrhea Or Gas?

Allergies Or Sensitivities?

Are Your Periods Regular?

How Many Days Is Your Flow?

How Frequent?

Is It Painful Or Symptomatic?

Please Explain:

Are You Reaching Or Approaching Menopause?

Birth Control History:

Do You Experience Yeast Infections Or Urinary Tract Infections?

Do You Take Any Supplements Or Medications?

Please List Supplements Or Medications:

What Role Do Sports And Exercise Play In Your Life?

What Foods Did You Eat Often As A Child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What Is Your Food Like These Days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Will Family And Friends Be Supportive Of Your Desire To Make Food And 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? If So, What?

The Most Important Thing I Should Change About My Diet To Improve My Health Is:

Additional Comments


Anything else you would like to share?