Email Address

Age

Height

Place of birth:

How often do you check your email?

Home Phone:

Work Phone:

Mobile Phone:

Current weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different?

If so, what?

Relationship status:

Where do you currently live?

Children?

Pets?

Occupation:

Hours of work per week:

Please list your main health concerns:

Any pain, stiffness, or swelling?

Other concerns and/or goals?

Constipation/diarrhea/gas?

At what point in your life did you feel best?

Allergies or sensitivities? Please explain:

Any serious illnesses/hospitalizations/injuries?

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:

How is/was the health of your mother?

How was/is 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?

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?

What foods did you often eat as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What is 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?

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:

Anything else you would like to share?

Women's Health History