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Women's Health Form

First Name*

Last name*

Email*

How often do you check e-mail?

Daily

Every couple days

Weekly

Phone*

Phone type*

Home

Work

Mobile

Preferred contact time(s)

Morning

Afternoon

Evening

Age

Height

Weight

Would you like your weight to be different?

Yes

If yes, what would you like to be different about your weight?

Relationship 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?

How is your sleep?

How many hours?

Do you wake up at night?

What are some of the reasons you wake up at night?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? (please explain)

Are your periods regular?

How 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)

Do you take any supplements or medications? (please list)

Any healers, helpers or therapies with which you are involved? (please list)

What role do sports and exercise play in your life?

What foods did you eat often as a child?

Do you cook?

What 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?

What is the most important thing I should do to improve my health?

Will family/friends be supportive of your desire to make lifestyle changes?

Any other comments?

This questionairre is based off of the Institute for Integrative Nutrition. It is being used with permission. It has been adapted.

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Women's Health Form

This questionairre is based off of the Institute for Integrative Nutrition. It is being used with permission. It has been adapted.

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