EmailMe Form - Women's Health History

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Confirm

How often do you check e-mail? (daily, weekly) *

Home Phone *

### - ### - ####

Work Phone

### - ### - ####

Cell Phone

### - ### - ####

Age *

Height *

Date of Birth *

MM / DD / YYYY

Place of Birth *

Current Weight *

Weight 6 months ago *

Weight one year ago *

Would you like your weight to be different? *

Yes

No

If so, what?

Social Information

Relationship Status *

Single

Married

Divorced/Widowed

Do you have children? *

Yes

No

Do you have pets? *

Yes

No

Occupation

Hours of work per week

Health Information

Please list your main health concerns *

Other concerns and/or goals? *

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

Any serious illness, hospitalizations, injuries? *

How is/was the health of your mother? *

How is/was the health of your father? *

What is your ancestry? (health issues, bloodlines) *

What blood type are you? *

Do you sleep well? *

Yes

No

How many hours? *

Do you wake up at night? *

Yes

No

If yes, why? Describe in detail.

Any pain, stiffness or swelling? *

Yes

No

Constipation, Diarrhea, Gas? *

Yes

No

Allergies or sensitivities? Please explain *

Are your periods regular? *

Yes

No

How many days is your flow? *

Please enter a value between 1 and 10.

How frequent? *

Painful or symptomatic? *

Painful

Symptomatic

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? *

Yes

No

Please List

Any healers, helpers, pets or therapies with which you are involved? *

Yes

No

Please List

What role do sports and exercise play in your life?

Food Information

What foods did you eat often as a child?

Breakfast *

Lunch *

Dinner *

Snacks *

Liquid *

What's your food like these days?

Breakfast *

Lunch *

Dinner *

Snacks *

Liquid *

Will family and/or 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? *

What percentage is not? *

Where do you get the rest from? *

Do you crave sugar, coffee, cigarettes, or have any major addictions? *

The most important thing I should change about my diet to improve my health is *

Additional Comments

Anything else you would like to share?