Women’s Health History Form Name * First Name Last Name Age * Height * Date of Birth * Place of Brith * Email * How often do yo check your email? Daily Weekly Monthly Rarely Home Phone Work Phone Mobile Phone Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? Yes No If Yes, How? Relationship Status Single In a relationship Married Divorced Where do you live? Any children? Yes No Any pets? Yes No Occupation How many hours do you work per week? What are your main health concerns? Any other concerns and/or goals? At what point in your life did 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? A B AB O 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? Yes No 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? Yes No Do you cook? Yes No What percentage of your food is home-cooked? Where does your non-home-cooked food come from? What foods did you eat often as a child? Breakfast -- Lunch -- Dinner -- Snacks -- Liquids What foods do you typically eat these days? Breakfast -- Lunch -- Dinner -- Snacks -- Liquids 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? Thank you! Massage Yoga Health Coaching
