Women's Health History

Women's Confidential Health History

Date: *

Name *

Referred by:

Address:

Email Address *

Phone Number: *

Age:

Date of Birth:

Height:

Current Weight:

Weight 6 Months Ago:

Weight 1 Year Ago:

Goal Weight:

Relationship Status:

Children:

Pets:

Occupation:

Number of Hours Working per Week:

Please List your Health Concerns:

Other Concerns and/or goals?

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

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

Do you sleep well?

How many hours?

Do you wake at night? Why?

Any pain/stiffness or swelling?

Are your periods regular?

Painful or symptomatic? Please explain:

Reached or approaching menopause? Please explain:

Do you experience yeast infections or UTIs? Please explain:

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any medications or supplements? Please list:

Any healers, helpers, or therapies? Please list:

What role does exercise play in your life? Please list all physical activities with frequency:

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

What percentage of your food is home cooked?

Do you cook?

Where do you get the rest from?

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

What foods did you eat often as a child? (For Breakfast, Lunch, Dinner and Snacks)

What is your diet like these days? (For Breakfast, Lunch, Dinner and Snacks)

Things I have tried in the past to improve my health:

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

Anything else you want to share?