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Women's Health Form
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Women’s Health History Form
Fill out the form below then submit. After you submitted the form, you will receive a confirmation email with a link to schedule a meeting. Thanks!
(denotes required field)
How often do you check your email?
often like everyday
few times a week
Telephone - Home:
Date of Birth:
Place of Birth:
Weight Six Months ago
Weight One Year ago:
Would you like your weight to be different?
If so, what?
Check the following:
I have children
I have pets
I have both
Don't have any
Hours of work per week:
Please list your main health concerns:
Other concerns and or goals?
At what point in your life did you feel best?
Any serious illness, hospitalizations or injuries?
How is/was the health of your father?
How is/was 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?
Any pain, stiffness or swelling?
Are your periods regular?
How many days is your flow?
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:
Constipation, diarrhea or gas? Please explain:
Allergies or sensitivities? Please explain:
Do you take any supplements or medications? Please explain:
Any healers, helpers or therapies with which you are involved? Please list:
What role does sports and exercise play in your life?
What foods did you eat often as a child?
What is your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you crave any of the following?
What percentage of your food is home cooked?
Do you cook?
All the time
Once or twice a week
I prefer to dine out
Where do you get the rest from?
The most important thing I should change about my diet to improve my health is:
Anything else you want to share?