Women’s Health Form Fill out the form below for your FREE 30 minute consultation! Women’s Health History Your Name Your Email How often do you check email? Phone Age Height Place of Birth Current Weight Weight six months ago Weight one year ago Would you like your weight to be different? Yes No If so, how? Relationship Status Where do you currently live? Children? Pets? Occupation How many hours per week? Please list your main health concerns: Other concerns and/or goals: At what point in life did you feel your 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 is your blood type? How is your sleep? How many hours do you normally get? Do you wake up at night? Why? Any pain, stiffness or swelling? Any constipation/diarrhea/gas? Any 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 an supplements or medications? Please list: Any healers, helpers or therapies in 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? Please list breakfast, lunch, dinner, snacks, and liquids. What foods do you eat these days? Please list breakfast, lunch, dinner, snacks, and liquids. Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? 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? The most important thing I should do to improve my health is: Anything else you would like to share? Submit Form Share this: Share on X (Opens in new window) X Share on Facebook (Opens in new window) Facebook Like this:Like Loading...