Health History - Woman - Brand New Day Wellness

Health History - Woman

PERSONAL INFORMATION

* Indicates required field

Name *

First

Last

Email *

How often do you check email? *

Cell Phone Number *

Home Phone Number *

Work Phone Number *

Age *

Height *

Birthdate *

Place of Birth *

Current Weight *

Weight 6 months ago *

1 year ago *

Would you like your weight to be different? and if so, what? *

SOCIAL INFORMATION

Relationship status: *

Where do you currently live? *

Children *

Pets *

Occupation *

Hours 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 illnesses/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? *

How is your sleep? *

How many hours? *

Do you wake up at night? Why? *

Any pain, stiffness or swelling? *

Constipation/Diarrhea/Gas? *

Allergies or sensitivities? Explain *

WOMAN'S HEALTH

Are your periods regular? *

How many days is your flow? *

How frequent? *

Painful or 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? Please list: *

Any healers, helpers or therapies with which you are involved? Please list: *

What roles 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/or lifestyle changes? *

Yes No

Do you cook? and What percentage of your food is home-cooked? *

Where do you get the rest of your food from that isn't home-cooked? *

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

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

Additional Comments *

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