Women's Health History Form

All of your information will remain confidential.

PERSONAL INFORMATION

First Name:

Last Name:

E-mail:

How often do you check e-mail?

Home Phone:

Work Phone:

Cell Phone:

Age:

Height:

Birthdate:

Place of Birth:

Current Weight:

Weight 6 months ago:

Weight 1 year ago:

Would you like your weight to be different?

If so, what?

SOCIAL INFORMATION

Relationship status:

Where do you currently live?

Children:

Pets:

Occupation:

Hours of work per week:

How would you rate your stress level? 1-10, low to high.

Enter a # from 1-10

What do you do to relax?

What are some of your favorite movies and/or books?

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 illnesses/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?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

WOMEN’S HEALTH

Are your periods regular?

How many days is 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 any supplements or medications? Please list:

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

What role do sports and exercise play in your life?

FOOD INFORMATION

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

Do you cook?

Will family/friends be supportive?

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?

The most important thing I should do to improve my health is:

ADDITIONAL COMMENTS

Anything else you would like to share?