Women's Health History - Easy Gluten Free Living

Contact

Name*

First Last

Address*

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

Home Phone*

Work Phone*

Mobile Phone*

Email*

Do you check your email daily?*

Yes
No

About You

Marital Status*

Employment*

Occupation*

Hours per Week*

Children*

Please enter 'N/A' if not not applicable

Pets*

Please enter 'N/A' if not not applicable

Please list forms of exercise and frequency.*

Please enter 'N/A' if not not applicable

Basic Health

Age*

Height*

Blood Type*

Where were you born?*

Weight*

Have you lost or gained more than 3 lbs in the last 6 months? Explain:*

Are you happy with your current weight?*

Yes
No
Unsure

If no, what would you like to change?*

Please enter 'N/A' if not not applicable

Do you take any supplements, multivitamins, or medications? Please list:*

Please enter 'N/A' if not not applicable

Are you or have you seen any healers, helpers, or therapies? Please list:*

Please enter 'N/A' if not not applicable

Sleep Habits

Do you sleep through the night?*

Please enter 'N/A' if not not applicable

Hours of sleep per night?*

Do you wake up at night or have trouble sleeping?*

If yes, why?*

Please enter 'N/A' if not not applicable

Medical

Physician*

Please enter 'N/A' if not not applicable

How do you feel?*

Family Medical History

How is/was your mother's health?*

How is/was your father's health?*

What is your ancestry?*

Women's Health

Are your periods regular?*

Yes
No
N/A

How many days is your flow?*

How frequent?*

Please enter 'N/A' if not not applicable

Painful or symptomatic? Please explain:*

Please enter 'N/A' if not not applicable

Birth control history? Please explain:*

Please enter 'N/A' if not not applicable

Do you experience urinary tract infections or yeast infections? Please explain:*

Please enter 'N/A' if not not applicable

Reached or approaching menopause?*

Please enter 'N/A' if not not applicable

Diet

Do you cook?*

What percentage of your food is homecooked?*

Where do you get the rest from?*

Please enter 'N/A' if not applicable

Any dietary restrictions?*

Please enter 'N/A' if not applicable

Allergies or sensitivities? Please explain:*

Please enter 'N/A' if not applicable

Constipation, diarrhea, or gas?*

Please enter 'N/A' if not applicable

Sugar, coffee, cigarettes?*

Please enter 'N/A' if not applicable

Will your family and/or friends support you in your healthy changes?*

Childhood Diet

What BREAKFAST foods did you eat often as a child?*

What LUNCH foods did you eat often as a child?*

What DINNER foods did you eat often as a child?*

What SNACK OR DESSERT foods did you eat often as a child?*

What BEVERAGES did you drink often as a child?*

Current Daily Diet

What does your typical BREAKFAST consist of?*

What does your typical LUNCH consist of?*

What does your typical DINNER consist of?*

What does your typical DESSERT consist of?*

What do your typical SNACKS consist of?*

What do your typical BEVERAGES consist of?*

Health Concerns

Any serious illnesses, hospitalizations, or injuries?*

Please enter 'N/A' if not not applicable

Any pain, stiffness, or swelling?*

Please enter 'N/A' if not not applicable

Please list your main health concerns:*

Any other concerns and/or goals?*

Please enter 'N/A' if not not applicable

The most important thing I want to achieve to improve my health is:*

Additional

Additional Comments:

Health History - Women's

Contact

About You

Basic Health

Sleep Habits

Medical

Family Medical History

Women's Health

Diet

Childhood Diet

Current Daily Diet

Health Concerns

Additional