Women's Health History If you are a human and are seeing this field, please leave it blank. Personal Information First Name * Last Name * Email * How often do you check e-mail? Home Phone Work Phone Mobile Phone Age Height Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 123456789101112141516171819202122232425262728293031 Year 200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940 Place of Birth Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? If so, what would you like your weight to be? Social Information Relationship Status SingleDivorcedMarriedWidowed Where do you currently live? Do you have childrent? If yes, how many and how old are they? Do you have pets? If yes, describe your pets. Occupation How many hours per week do you work? 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? Do you wake up at night? If yes, why? Do you have any pain, stiffness or swelling? Describe. Do you suffer fom constipation, diarrhea or gas? Do you have allergies or sensitivities? Please explain: Women's Health Are your periods regular? How many days is your menstrual 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: 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 InformationWhat foods did you eat often as a child? Breakfast: Lunch Dinner Snacks: Drinks: What is your food like these days? Breakfast: Lunch: Dinner: Snacks: Drinks: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Do you cook? 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: Additional Comments Anything else you would like to share?
Women's Health History