Women’s Health History All of your information will remain confidential. Step 1 of 5 20% Name* First Last Email* How often do you check emailHome PhoneWork PhoneMobile PhoneAgeHeightBirthdate Place of Birth:Current weightWeight six months ago:One year ago:Would you like your weight to be different?YesNoWeight goal Social InformationRelationship status:Where do you currently live?Children:Pets:Occupation:Hours of work per week: Please list your main health concerns:Other concerns and/or goals:At what point in your life did you feel best?Any serious illnesses/hospitalizations/injuries?How is/was the health of your mother?How is/was the health of your father?What is your ancestry?What blood type are you?How is your sleep?How many hours?Do you wake up at night?YesNoWhy?Any pain, stiffness or swelling?YesNoConstipation/Diarrhea/Gas?YesNoAllergies or sensitivities? Please explain:Are your periods regular?YesNoHow many days is your flow?How frequent?Painful or symptomatic? Please explain:Reached or approaching menopause? Please explain:Birth control history:Do you experience yeast infections or urinary tract infections? Please explain: Medical InformationDo you take any supplements or medications? Please list:Any healers, helpers or therapies with which you are involved? Please list:What roles do sports and exercise play in your life? Food Information What foods did you eat often as a child?Breakfast:Lunch:Dinner:Snacks:Liquids:What is your food like these days?Breakfast:Lunch:Dinner:Snacks:Liquids:Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?Do you cook?YesNoWhat percentage of your food is home-cooked?Where do you get the rest from?Do you crave sugar, coffee, cigarettes, or have any major addictions?The most important thing I should do to improve my health is:Additional Comments Anything else you would like to share?