Request edit access
Health History Woman
Email address *
Name *
Where do you currently live? *
Phone number
Age, Birth date and Place of Birth
Weight today
Weight 6 months ago and 1 year ago?
Would you like your weight to be different? And if so what?
Relationship status
Do you have children?
How many hours per week do you work?
Are you happy with your current occupation?
How would the ideal job look for you?
Please list your main health concerns?
Other concerns and goals
At what point in your life did you feel best?
Any serious illnesses, hospitalization or injuries?
How was the health of your mother?
How 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?
Do you wake up at night? Why?
Any pain, stiffness, or swelling?
Constipation, Diarrhea, Bloating? Please explain.
How many times do eliminate during a day?
Do you have allergies?
Do you suspect that you have any food sensitivities? If so please explain?
Are your periods regular?
How many days is your flow?
Do you have heavy or light bleeding?
Is it painful or symptomatic? Please explain.
Have you noticed special cravings during your cycle?
Reached or approaching menopause? Please explain.
Birth control history.
If you have children, how was their births. Please explain.
Do you experience yeast infections or urinary tract infections? Please explain.
Do you take any medications or supplements? 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 role does nature play in your life?
What foods did you eat often as a child? Breakfast, lunch, snack, dinner and drinks.
What is your food like these days? Breakfast, Lunch, Snacks, Dinner, Drinks.
How much water do you drink per day?
What kind of water do you drink?
Do you eat organic food, what percentage?
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 from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Do you drink alcohol? How much and how often?
Do you take any drugs? Please explain.
The most important thing I should do to improve my health is:
Name 3 things that you know, that if you put them into practice, you would feel healthier.
Do you have a spiritual practice?
On a scale from 1 to 10, how important is to improve your health now for you?
On a scale from 1 to 10, how confident do you feel that you will be able to make the changes that you want to do?
On a scale from 1 to 10, how much time are you willing to invest in your health right now?
Anything else you would like to share?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service