Womans Health History 1234567 PersonalName(Required) First Last AgeHeightDate of Birth MM slash DD slash YYYY Place of BirthEmail(Required) How often do you check your email?Home PhoneWork PhoneMobile PhoneWeight Six Months AgoCurrent WeightWeight Six Year AgoWould you like your weight to be different?If so, how? SOCIALRelationship StatusWhere do you live?Any pets?OccupationHow many hours do you work per week? GENERAL HEALTHWhat 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 to food, medications, supplements? WOMEN’S HEALTHAre 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: MEDICALList all supplements or medications:Are you involved with any healers, helpers, or therapies?What role do sports and exercise play in your life? FOODWill 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?BreakfastLunchDinnerSnacksLiquids Add RemoveWhat foods do you typically eat these days?BreakfastLunchDinnerSnacksLiquids Add RemoveDo 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 COMMENTSIs there anything else you would like to share?CAPTCHA Δ
