Confidential Health History for Women Name * First Name Last Name Email Address * Mobile Phone * (###) ### #### Age Height Weight Children Relationship Status Occupation 3 Primary Health Concerns * At what point in your life did you feel your best? Why? Any serious illnesses/hospitalizations/injuries? * How is/was your mother's health? How is/was your father's health? What is your ancestry? What is your blood type? Were you breastfed or bottle fed? Do you sleep well? How many hours? Do you wake at night? Why? * Any pain, stiffness or swelling? * Menstrual Cycle * No flow due to pregnancy No flow due to menopause No flow due to birth control Irregular flow due to peri-menopause Regular flow without discomfort Regular flow with discomfort Irregular flow with no discomfort Irregular flow with discomfort Other Pregnancy due date, birth control and/or menopause history * History of yeast or urinary tract infections? Explain: * Constipation, gas or diarrhea? Explain: * Allergies or sensitivities (seasonal, dietary, environmental, etc)? Explain: * Please list medications you take, what they are for, and how long you've been taking them: * Please list any healing therapies you are using (acupuncture, massage, chiropractic, hypnosis, etc): * What role do sports and exercise play in your life? * Check off foods you ate often as a child: * Pork (ham, bacon, roast, chops) Chicken Beef Hot dogs, cold cuts, deli meats Fish BBQ Wild game meats Raw veggies Fresh cooked greens - collards, mustard, kale, etc Fresh cooked vegetables Frozen vegetables Canned vegetables Fresh fruit Frozen fruit Canned fruit Fresh cooked beans Frozen beans Canned beans Homemade soups Canned soups Nuts - cashew, pecan, macadamia Nuts - almond, walnut, pistachio, pine, Brazil Seeds - sunflower, pumpkin, chia White Rice Brown rice Quinoa Millet White Potatoes Sweet potatoes or Yams Corn Grits / hominy Pasta Soy - beans, milk, meats Oats White bread, rolls, buns Wheat bread, rolls, buns Homemade bread Butter Margarine Dairy - milk, cheese, yogurt, ice cream Eggs Jellies and jams Pickles, relish or sauerkraut Ketchup, mayo, mustard, dressings Potato chips Candy - not chocolate Candy - chocolate Cupcakes, donuts, cookies Pies, cakes, streusels Salsa, hummus, dips Hot lunch at school Sandwiches from home Fast food - McDonald's, Wendy's, Burger King, White Castle, Arby's, Taco Bell, Subway, etc Water Kool-Aid Crystal Lite Hi-C Soda pop - Coke, Pepsi, Mt Dew, Dr Pepper, Sprite, Orange, Grape, etc Fresh juices Bottled juices Canned juices Coffee or energy drinks Herbal Teas Check all that apply to your childhood: * Mealtimes were joyous family events I ate full meals several times a day I mostly snacked on junk throughout the day I mostly ate in front of the television I mostly ate in silence at a table with others I mostly ate somewhere by myself The only time I ate with others was during holidays My family gathered for at least one meal each week Children ate in the kitchen away from the adults We often had others join us for meals We often ate out or had take-out (pizza, Chinese, etc) My mother/father/parents/grandparent loved to cook I cannot remember childhood meal times What's your food like these days - breakfast, lunch, dinner, snacks, beverages? * Check all that apply today: * Mealtimes are joyous family events I eat full meals several times a day Instead of meals, I mostly snack throughout the day I mostly eat in front of the television, at my desk, or in the car I mostly eat in silence at a table with others I mostly eat somewhere by myself The only time I eat with others is during holidays My family gathers for at least one meal each week My children eat in the kitchen away from the adults I often share a meal with friends at a restaurant I love to cook and often invite others to meals at my home I don't cook but enjoy the company of others at meal times I travel a lot so meals are not planned, inconsistent or an afterthought I can never remember what I ate yesterday What % of your food is home prepared and cooked? * Where does the rest of your food come from? * Tell me about your cravings - food, sugar, salt, coffee, cigarettes, binge eating, etc ... : * Do you crave nonfood items: dirt, ice, laundry starch, paint chips, coffee grounds, etc? If so, which, and for how long? * Who in your life supports your desire to make changes? * The most important thing I should change about my diet to improve my health is ... * THREE things I know I should be doing for my health & wellbeing but am not, are ... Anything else you'd like to share? * Thank you!
