Women’s Confidential Health History Intake Form Column 1 First Name Email Telephone Work Telephone Cell Height Column 2 Surname How often do you check your email Telephone Home Age Under 18 18-24 25-34 35-44 45-54 55-64 65 or Above Prefer Not to Answer Date and Place of Birth Column 1 Current Weight Weight A Year Ago Column 2 Weight Six Months ago Could Your Weight To Be Different? Full Width Column If so tell us how? Column 1 Relationship Status Occupation Column 2 Children One Two Three Four Five Six More Hours of work per week Full Width Column Please list your main health concerns: Other concerns and/or goals Any serious illnesses/hospitalizations/injuries? Column 1 When in your life did you feel best? How is the health of your father? What is your blood type? How many hours? Column 2 How is the health of your mother? What is your ancestry? Do you sleep well? Do you wake up at night? Full Width Column If so why? Any pain, stiffness or swelling? Column 1 Birth control history: How frequent? Column 2 Are your periods regular? How many days is your flow? Full Width Column Painful or symptomatic Periods? Please explain: Reached or approaching menopause? Please explain: Birth control history: Do you experience yeast infections or urinary tract infections? Please explain: Do you have any digestive issues? Do you experience pain/gas/bloating/heartburn after eating? Constipation/Diarrhea/Gas? Please explain: Allergies or sensitivities? Please explain: Any other medical conditions now or historically? Please list: Do you take any supplements or medications? Please list: Any healers, helpers or therapies with which you are involved? Please list: What role does sports and exercise play in your life? What foods did you eat as a child? Breakfast Lunch Dinner Liquids Snacks What’s your food like these days? Breakfast Lunch Dinner Liquids Snacks Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Column 1 What % of your food is home cooked? Other sources? Column 2 Do you cook? Do you have any major addictions? Full Width Column The most important thing I should change about my diet to improve my health is: Anything else you want to share? If you are human, leave this field blank. Submit
