Female Health History

Personal Information

First Name (required):

Last Name (required):

Your Email (required):

How often do you check email?:

Home Phone:

Mobile Phone:

Work Phone:

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 you want your weight different, what would you like it to be?:

Social Information

Relationship Status:

Where do you current live?:

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 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 of sleep?:

Do you wake up at night?:

If 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 is your period?:

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 for breakfast, lunch, dinner, snacks, and liquids?:

What is your food like these days for breakfast, lunch, dinner, snacks, and liquids?:

Will family and/or 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 do you get the rest of food 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 Information

Anything else you would like to share?: