Women's Health Intake Form - THE NEW FACE OF 60 by Rosanna Jenkins

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Personal Information
First Name*
Last Name*
Email*
How often do you check e-mail
Home Phone
Work Phone
Mobile Phone
Age
Height
Date
Date Format: MM slash DD slash YYYY
Place of Birth
Current weight
Weight six months ago
One year ago
Would you like your weight to be different?
- Yes
- No
If so, what?

Social Information
Relationship status
Where do you currently live?
Children
Pets
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 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 explain
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain
Reached or approaching menopause? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain

Do you take any supplements or medications? Please list
Any healers, helpers or therapies with which you are involved? 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
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
- Yes
- No
What 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 is
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids

Additional Comments
Anything else you would like to share?
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