Health History Form Women

1. First Name(required)
2. Last Name(required)
3. Email(valid email required)
4. How often do you check email?(required)
5. Address(required)
6. Home phone(required)
7. Work phone
8. Cell phone(required)
9. Age(required)
10. Height(required)
11. Birthdate(required)
12. Place of birth(required)
13. Current Weight(required)
14. Weight 6 months ago(required)
15. Weight 1 year ago(required)
16. Would you like your weight to be different?(required)
17. If so, what?(required)
18. Relationship status(required)
19. Children? How many?(required)
20. Pets?(required)
21. Occupation(required)
22. Hours of work per week(required)
23. Please list your main health concerns(required)
24. Other concerns and/or goals?(required)
25. At what point in your life did you feel your best?(required)
26. Any serious illness/hospitalizations/injuries?(required)
27. How is the health of your mother?(required)
28. How is the health of your father?(required)
29. What is your ancestry?(required)
30. What blood type are you?(required)
31. Do you sleep well?(required)
32. How many hours?(required)
33. Do you wake up at night?(required)
34. Why?(required)
35. Any pain, stiffness, or swelling?(required)
36. Constipation/Diarrhea/Gas? Please explain(required)
37. Allergies or sensitivities?(required)
38. Are your periods regular?(required)
39. How many days is your flow?(required)
40. How frequent?(required)
41. Painful or symptomatic?(required)
42. Please explain:(required)
43. Reaching or approaching menopause?(required)
44. Please explain:(required)
45. Birth control history(required)
46. Do you experience yeast infections or urinary tract infections? Please explain:(required)
47. Do you take any supplements or medication?(required)
48. Please list:(required)
49. Any healers, helpers, pets or therapies with which you are involved?(required)
50. Please list:(required)
51. What role do sports and exercise play in your life?(required)
52. What foods did you eat often as a child?(required)
53. Breakfast(required)
54. Lunch(required)
55. Dinner(required)
56. Snacks(required)
57. Liquids(required)
58. What's your food like these days?(required)
59. Breakfast(required)
60. Lunch(required)
61. Dinner(required)
62. Snacks(required)
63. Liquids(required)
64. Will family/friends be supportive of your desire to make food and/or lifestyle changes?(required)
65. Do you cook?(required)
66. What percentage of your food is home cooked?(required)
67. Where do you get the rest from?(required)
68. Do you crave sugar, coffee, cigarettes, or have any major addictions?(required)
69. The most important thing I should change about my diet to improve my health is:(required)
70. Anything else you would like to share?(required)

 

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