Women's Health History Form

Personal Information

Name

FirstLast

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Home Phone:

Work Phone:

Email

Age

Please enter a value between 0 and 100.

Height

Birthday

MM

DD

YYYY

Place of Birth:

Current Weight:

Weight six months ago:

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:

Other concerns and/or goals?:

At what point in your life did you feel best:

Any serious illness/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?:

Do you sleep well?:

How many Hours?:

Do you wake up at night?:

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:

Reaching or Approaching Menopause? Please Explain:

Birth control history:

Do you experience yeast infections or urinary tract infections? Please explain:

Medical Information

Do you take any supplements or medications? Please List:

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

What role do sports and exercise play in your life?:

Food Information

What foods do you eat in a typical day?:

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:

Do you like to cook?:

If your answer is no, what typically holds you back?:

What percentage of your food is not made in your home?:

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:

Additional Comments

Anything else you would like to share?:

Women’s Health History Form