Women's Confidential Health History
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Name *
Adress *
E-mail Address: *
Phone: *
Date of Birth *
MM
/
DD
/
YYYY
Place of Birth *
Height *
Current Weight *
Weight 6 months ago? *
Weight one year ago? *
Would you like your weight to be different? *
If yes, please indicate? *
Relationship Status? *
Children? *
If yes, please select from the list below.
Clear selection
Occupation? *
Hours of work per week? *
Please list your main health concerns.
At what point in your life did you feel your best? *
Other concerns or goals?
Any serious illness, hospitalization or injuries? *
If yes, please explain.
How is the health of your mother? *
How is the health of your father?
What is your ancestry? *
What is your blood type? *
Do you sleep well? *
If no, please explain.
How many hours per night? *
Do you wake up at night? *
If yes, please explain.
Any pain, stiffness or swelling? *
If yes, please explain.
Are your periods regular? *
How many days is your flow? *
How frequent? *
Painful or symptomatic? *
If yes, please explain.
Please note your birth control history. *
Do you experience yeast infections or urinary tract infections? *
If yes, please explain.
Do you experience constipation, diarrhea, gas? *
If yes, please explain.
Allergies or sensitivities? *
If yes, please explain.
Do you take any supplements or medications? *
If yes, please list.
What role do sports and exercise play in your life?
What foods did you eat often as a child for breakfast? *
What foods did you eat often as a child for lunch? *
What foods did you eat often as a child for dinner? *
What foods did you eat often as a child for snacks? *
What liquids did you drink often as a child? *
What is your food intake like now for breakfast? *
What is your food intake like now for lunch? *
What is your food intake like now for dinner? *
What is your food intake like now for snacks *
What is your intake like now for liquids? *
Will family and friends be supportive of your desire to make food lifestyle changes? *
What percentage of your food is home cooked? *
Do you cook? *
Where do you get the rest from? *
Do you crave coffee, sugar, cigarettes or have any other addictions? *
If yes, please explain. *
What do you feel is the most important thing that you need to change about your diet to improve your health? *
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