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Women's Health Form
First Name*
Last name*
Email*
How often do you check e-mail?
Daily
Every couple days
Weekly
Phone*
Phone type*
Home
Work
Mobile
Preferred contact time(s)
Morning
Afternoon
Evening
Age
Height
Weight
Would you like your weight to be different?
No
Yes
If yes, what would you like to be different about your weight?
Relationship status
Where do you currently live?
Children
Pets
Occupation
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 illnesses/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
How is your sleep?
How many hours?
Do you wake up at night?
What are some of the reasons you wake up at night?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas?
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)
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 eat often as a child?
Do you cook?
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?
What is the most important thing I should do to improve my health?
Will family/friends be supportive of your desire to make lifestyle changes?
Any other comments?
Signature*
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