Health Form

Personal Information

Name*

First Last

Email

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How often do you check e-mail?

Home Phone

Work Phone

Mobile Phone

Age

Height

Date of Birth

Place of Birth

Current weight

Weight six months ago

Weight one year ago

Would you like your weight to be different?

Yes
No

What would you like to weigh?

Social Information

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week?

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 is your blood type?

How is your sleep?

How many hours do you sleep on average a night?

Do you wake up at night?

Yes
No

Why?

Any pain, stiffness or swelling?

Yes
No

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

Reached or approaching menopause? Please explain:

Birth control history:

Do you experience yeast infections or urinary tract infections? Please explain:

Medical Information

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?

On a scale of 1 to 10, how would you rate the amount of stress in your life?

1 being very low stress, 10 being very high stress

Food Information

Breakfast

Lunch

Dinner

Snacks

Liquids

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

Do you cook?

Yes, all the time
Sometimes
Rarely
Never

What percentage of your food is home-cooked?

From where do you get the rest of your meals?

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