Female Health History

Form adapted from the Institute of Integrative Nutrition.

PERSONAL INFORMATION

Name

First Name

Last Name

Phone

How often do you check email?

Birthdate

YYYY

Height

Weight

Would you like your weight to be different? If so, what?

SOCIAL INFORMATION

Relationship status

Do you have any children? Any pets?

What is your occupation?

How many hours do you work each week?

HEALTH INFORMATION

Please list your main health concerns.

At what point in your life did you feel your best?

Any serious illnesses, hospitalizations, or 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? Why?

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas?

Allergies or sensitivities? Please explain.

WOMEN'S HEALTH

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.

MEDICAL INFORMATION

Do you take any supplements or medications? Please list.

Any healers, helpers, or therapies with which you are involved? Please explain.

What role do sports and exercise play in your life?

FOOD INFORMATION

What foods did you eat often as a child?

What is your food like these days?

Will family and/or friends be supportive of your desire to make food and 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 other major addictions

The most important thing I should do to improve my health is...

ADDITIONAL INFORMATION

Anything else you would like to share?