Women’s Health Intake Form Step 1 of 6 16% Personal InformationFirst Name*Last Name*Email* How often do you check e-mailHome PhoneWork PhoneMobile PhoneAgeHeightDate Date Format: MM slash DD slash YYYY Place of BirthCurrent weightWeight six months agoOne year agoWould you like your weight to be different?YesNoIf so, what? Social InformationRelationship statusWhere do you currently live?ChildrenPetsOccupationHours of work per week Health InformationPlease list your main health concernsOther concerns and/or goals?At what point in your life did you feel best?Any serious illnesses/hospitalizations/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?Constipation/Diarrhea/Gas?Allergies or sensitivities? Please explainAre your periods regular?How many days is your flow?How frequent?Painful or symptomatic? Please explainReached or approaching menopause? Please explainBirth control historyDo you experience yeast infections or urinary tract infections? Please explain Do you take any supplements or medications? Please listAny healers, helpers or therapies with which you are involved? Please listWhat role do sports and exercise play in your life? Food InformationWhat foods did you eat often as a child?BreakfastLunchDinnerSnacksLiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes?Do you cook?YesNoWhat percentage of your food is home-cooked?Where do you get the rest from?Do you crave sugar, coffee, cigarettes, or have any major addictions?The most important thing I should do to improve my health isWhat is your food like these days?BreakfastLunchDinnerSnacksLiquids Additional CommentsAnything else you would like to share?Print your nameDraw your signature
