Women's Confidential Health History

contact

Name

Address

City

State

Zip

Telephones
Work
Home
Mobile
Email

How often do you check email?

personal & goals Age

Height

Date of Birth

Place of Birth

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different?

If so, what?

Relationship Status

Children

Pets

Occupation

Hours of Work per Week

What are your main health concerns?

Other concerns and/or goals?

medical history At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is the health of your father?

How is the health of your mother?

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? Please explain:

Allergies or sensitivities? Please explain:

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?

reproductive 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:

food What foods did you eat often as a child?

Breakfast
Lunch
Dinner
Snacks
Liquids

What's your food like these days?

Breakfast
Lunch
Dinner
Snacks
Liquids

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

Do you crave sugar, coffee, cigarettes, or have any major addictions?

What percentage of your food is home cooked?

Do you cook?

Where do you get the rest from?

The most important thing I should change about my diet to improve my health is:

finish up What role, if any, does spirituality play in your life?

What are two goals you have for the next year?

Is there anything else you would like to share?

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