Women’s Health History Form

Women's Health History

Name*
First Last
Email*
How often do you check email?
Home Phone
Work Phone
Mobile Phone
Age
Height
Birthdate
MM
DD
YYYY
Place of Birth
Current Weight (lbs)
Weight 6 Months Ago (lbs)
Weight 1 Year Ago (lbs)
Would you like your weight to be different?
- Yes
- No
If so, what?
Social Information
Relationship Status
- Single
- Married
- Dating
- Widowed
Where do you currently live?
Children:
Pets:
Occupation:
Hours of Work per week:
Health Information
Other concerns and/or goals?
Please list your main health concerns:
Any serious illnesses, hospitalizations, or injuries?
At what point in your life did you feel your best?
How is the health of your mother?
How is the health of your father?
What is your ancestry?
What is your blood type?
How is your sleep?
How many hours?
Do you wake at night?
Why?
Any pain, stiffness or swelling?
Constipation, gas, diarrhea?
Allergies or sensitivities? Please explain.
Are your periods regular?
How many days in your flow?
How frequent?
Painful or symptomatic? Please explain.
Reached or approaching menopause? Please explain.
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain.
Medical Information
Do you take supplements or medications? Please list.
Any healers, helpers or therapies with which you are involved? Please list.
What roles do sports and exercise play in your life?
Food Information
Diet Growing Up: Breakfast
Current Diet: Breakfast
Lunch
Lunch
Dinner
Dinner
Snack
Snack
Liquids
Liquids
Will family and friends support your desire to make food/lifestyle changes?
Do you cook?
What percentage of your food is home cooked?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I can do to improve my health is:
Anything else you would like to share?

Women's Health History

Social Information

Health Information

Medical Information

Food Information