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