Women's Confidential Health History
Please write or print clearly
Email address: How often do you check email?
Telephone – Work:
Date of Birth:
Place of Birth:
Weight six months ago:
One year ago:
Would you like your weight to be different? If so, what?
Hours of work per week:
Please list your main health concerns:
Any serious illness/hospitalizations/injuries?
How is the health of your mother?
How is the health of your father?
What is your ancestry? What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night?
Any pain, stiffness or swelling?
Are your periods regular?
How many days is your flow?
Painful or symptomatic? Please explain:
Birth control history:
Vaginal infections, reproductive concerns?
Do you take any supplements or medications? Please list:
Any healers, helpers, pets 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?
What’s your food like these days?
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?
Anything else you would like to share?