Women's Confidential Health History
Email address *
Name *
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Address *
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How often do you check email? *
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Best telephone number to be reached at? *
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Age *
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Height *
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Date of Birth *
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Place of Birth *
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Current weight? *
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What was your weight 6 months ago? *
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What was your weight 1 year ago? *
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Would you like your weight to be different? If so, what? *
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Relationship Status? *
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Children? *
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Pets? *
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Occupation? *
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How many hours do you work per week? *
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Please list your main health concerns: *
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Other concerns and/or goals? *
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At what point in your life did you feel best? *
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Any serious illness/hospitalization/injury? *
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How is/was the health of your mother? *
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How is/was the health of your father? *
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What is your ancestry? *
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What is your blood type? *
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Do you sleep well? *
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How many hours do you sleep at night? *
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Do you wake up at night? If so, why? *
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Any pain, stiffness, or swelling? *
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Are your periods regular? How many days is your flow? How frequent? *
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Are your periods painful or symptomatic? *
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Have you reached or approached menopause? Please explain. *
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What is your birth control history? *
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Do you experience yeast infections or urinary tract infections? If so, please explain. *
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Do you experience constipation/diarrhea/gas? Please explain. *
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Allergies or sensitivities? Please explain. *
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Do you take any supplements or medications? Please list. *
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Are there any healers, helpers, or therapies in which you are involved? Please explain. *
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What role does sports and exercise play in your life? *
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What foods did you eat often as a child for breakfast? *
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What foods did you eat often as a child for lunch? *
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What foods did you eat often as a child for dinner? *
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What foods did you eat often as a child for snacks? *
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What liquids did you consume often as a child? *
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What is your food like for breakfast these days? *
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What is your food like for lunch these days? *
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What is your food like for dinner these days? *
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What is your food like for snacking these days? *
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What is liquids do you consume these days? *
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Will your family and/or friends be supportive of your lifestyle and/or food changes? *
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What percentage of your food is home cooked? Do you cook? *
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Where do you get the rest of your food from? *
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Do you crave sugar, coffee, cigarettes, or have any other major addictions? *
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The most important thing I should change about my diet to improve my health is. . . *
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What do you do for fun? To engage yourself? For yourself? Mind body? *
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