Women’s Health History Personal InformationName* First and Last Name Phone*Email* How much screen time per day (in hours)?Please only enter a number, nothing else.Place of birthAgeBirthday Date Format: MM slash DD slash YYYY Current WeightWeight 6 months agoWeight 1 year agoWould you like your weight to be different?YesNoIf so, what?HeightFamily InformationRelationship StatusWhere do you currently live?Children's names and agesPets (names + types)Career and SocialOccupationHours of work per weekWhat do you do for fun?How is your social life?Health InformationPlease list your main health concernsOther health 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 do you wake up?Any pain, stiffness, or swelling?Constipation / Diarrhea / Gas?How often?What causes it?Allergies or sensitivities? Please list.Women's HealthAre your periods regular?YesNoHow many days is your flow?How frequent?Painful or symptomatic? Please explain.Reached or approaching menopause? Please explain.Birth Control HistoryDo you experience yeast infections or urinary tract infections? Please explain.Medical InformationHistory of AntibioticsDo you take any supplements or medication? Please list.Support and Self NurturingWhat role do sports and exercise, play, and movement have in your life?What do you like to do? What brings joy to your life?Habits, hobbies, interests?MovementWhat do you do for movement?Do you enjoy it?YesNoHow many times per week?DurationIf you don't move, what keeps you from physical activity?Food InformationWhat foods did you eat often as a child? And what is your food like these days?Breakfast (Child)Breakfast (Now)Lunch (Child)Lunch (Now)Dinner (Child)Dinner (Now)Snacks (Child)Snacks (Now)Liquids (Child)Liquids (Now)Will family and / or friends be supportive of your desire to make food and / or lifestyle changes?Do you cook?YesNoWhat percentage of your foods is home-cooked?Where do you get the rest from?Do you crave sugar, caffeine, alcohol, cigarettes or have any other addictions?How often?How much?Daily?Is it different on the weekends?Would you like to make a change in any of these areas?What do you think is the most important thing you could do to improve your health?Goals and ExpectationsPlease list your goals and expectations here.What are your expectations of me? How do you feel I can help you?Additional CommentsAnythings else you would like to share?
