Health History Questionnaire

Women's Health History

First name

Last name

Age

Height

DOB

Place of Birth

How often do you check your email?

Home Phone

Work Phone

Mobile Phone

Current Weight

Weight 6 Months Ago

Weight 1 Year Ago

Would you like your weight to be different?

yes no

if yes, how so?

Relationship Status

Where do you live?

Any children or pets?

Occupation: How many hours do you work per week?

What are your primary health concerns?

Any other concerns or goals?

At what point in your life do you feel your best?

Any current or previous serious illnesses, hospitalizations, or injuries?

How is/was your mother’s health?

How is/was your father’s health?

What is your ancestry?

What is your blood type?

How is your sleep?

How many hours do you sleep per night?

Do you wake up during the night? If so, why?

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas?

Any allergies or sensitivities?

Are your periods regular?

How many days is your flow?

How frequent?

Are your periods painful or symptomatic? If so, please explain:

Have you reached or are you approaching menopause? If so, please explain:

What is your birth control history?

Do you experience yeast infections or urinary tract infections? If so, please explain:

List all supplements or medications:

Are you involved with any healers, helpers, or therapies?

What role do sports and exercise play in your life?

Will your family and friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

What foods did you eat as a child?

What foods do you typically eat these days?

Do you crave sugar, coffee, or cigarettes?

Do you have any other major addictions?

What is the most important thing you should change about your diet to improve your health?

Is there anything else you would like to share?

I acknowledge that I am about to submit my health information online.

Women's Health History

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