Women's Health History Form Name:Address:EmailHow often do you check your email?Cell NumberText Friendly?AgeHeightDate of Birth:Place of Birth:Current Weight:Weight six months ago:One year ago:Would you like your weight to be different?If so, what?Relationship status:Partner's name?Children:....Name(s) & Ages(s).... Health Issues.... Occupation:Hours of work per week:What is your Primary health concern?What is your secondary health concern?What are you top 3 HEALTH GOALS?At what age in your life did you feel best?Do you want to get back to that state of vitalityPlease describe all serious illnesses/hospitalizations/injuries, date, durationDigestive Symptoms: Heartburn, GERD, Bloating/Gas, Constipation, IBSFrequencyOver how many yearsAny Known Food Allergies or Triggers?Chronic Headaches or Migraines?Frequency?Duration?Over How Many Years?Any known Triggers? Joint or back pain, stiffness or swelling? Where? Severity? Frequency? Duration?Low Energy?Dry Skin?Cold Hands or Feet?Frequent colds/flu?Sinus infections?Seasonal allergies?What symptoms?Are you post-menopause? Y/NAre your cycles regular?How many days is your flow?How frequent?Are you experiencing hot flashes and/or night sweats?Are your cycles painful? Do you feel emotionally stressed before or during your cycles?Birth control history & current use:Do you experience yeast infections? Y/N Urinary tract infections (UTIs)? Y/NFrequency?Current medication(s) or supplement(s), Name, Brand, Purpose, Dosage & Frequency:Do you use toxin-free body & personal care products? Y/ NWhat products & brand(s)?Do you use toxin-free cleaning supplies in your home? Y/NWhat products & brand(s)?Name(s) and types of current healthcare providers, ie,Primary Care, Chiro,:etcType(s) of Exercise? How Long? How many times per week?How many hours spent outdoors in the sunshine per week?How many hours spent relaxing, reading, writing, listening to music or meditating per week?Do you fall asleep easily? Y/ NStay asleep? Y/NHow many hours do you sleep a night?Do you awake feeling refreshed & energized? Y/ NDo you feel energized throughout the day? Y/NWhat foods do you usually choose? Breakfast Lunch Dinner Snacks LiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes?What percentage of your food is home cooked?Do you like to cook?Where do you get the rest from?o you crave sugar, coffee, cigarettes/ vaping, or alcohol? Any other biochemical dependencies?What is the most important change that would help you create a healthier lifestyle?Do you think that you could make better choices over time if you knew WHAT would help you get healthier?How do you think you would benefit from science-based EDUCATION, SUPPORT and GUIDANCE that would teach you how REGAIN and MAINTAIN your physical health and happiness?Is there anything else that you want to share?Send to Medea
