Women’s Health History Form Name(required) Email(required) Phone(required) Age(required) Birthdate(required) Height(required) Current weight Weight one year ago? Would you like your weight to be different? Yes No I just want to be healthy! Maybe but only if it is a result of being healthy. Relationship Status Married Single Other Where do you currently live? Children? Pets? Occupation? Hours of work per week: Please list your main health concerns: Other concerns and/or goals? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? 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? A AB B O Don't know How is your sleep? How many hours per night do you sleep? Do you wake up at night? If so, why? Allergies or sensitivities? Please explain: 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: Any healers, helpers or therapies with which you are involved? Please list: What role do sports and exercise play in your life? Do you take any supplements or medications? Please list:(required) What did you typically eat for breakfast, lunch, dinner, and snacks as a child? What do you typically eat for breakfast, lunch, dinner, and snacks now? What liquids did you drink as a child? What liquids do you drink now? Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Do you cook? What percentage of your food is home-cooked? Where do you get the rest of your food from? Do you crave sugar, coffee, cigarettes, or have any major addiction? The most important thing I should do to improve my health is:(required) Anything else you would like to share?