Health History Form – Women Health History Intake FormDate Personal InformationFirst and Last name *Email *How often do you check your email? *Home Phone *Work Phone Mobil Phone *Age *Height Birth Date *Current weight *Weight 6 months ago Weight 1 year ago Would you like your weight to be different? YesNoIf so, what? *Social InformationRelationship Status *Where do you currently live? Children? Pets? Occupation? Number of hours per week? Health InformationPlease list your top 5 health concerns: Please list in order of importance. What were the specifics of those issues?Other concerns and/or goals? At what point in your life did you feel best? Any serious illnesses/hospitalizations/injuries? Have you had a round of antibiotics? If so, when and how long? *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? ABO+/-ABHow is your sleep? *Select all that apply.Excellent, I never have a problem.I wake up 1-2 times per night.I can't fall asleepI wake up more than 2 times per nightI wake up between 1am and 4am a lotI can't stay asleepHow many hours? Why do you wake up at night? Any pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: *Woman's HealthAre your periods regular? yesnoHow 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: Libido, low or normal? Please Explain. Medical InformationWere you a C-section? *YesNoI don't knowDo you take any supplements or medications? Please list: *Any healers, helpers, or therapies with which you are involved? Please list: *Massage, Naturopath, Chiropractor, Acupuncture, Reiki, Counceling, Other Therapies, etc.What role do sports and exercise play in your life? Food InformationWhat foods did you eat often as a child?Breakfast? Lunch? Dinner? Snacks? Liquid? What is your food like these days?Breakfast? Lunch? Dinner? Snacks? Liquids? Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? yesnoDo 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 is: Who else is involved in making your health decisions? *Please list relationship and name.If the issues persisted what would be the cost to them personally? *confidence, finances, energy, happiness, joy, peace of mind, etc...Where are you on the scale of 1-10 to fix your health concerns? *What is your level of urgency to fix your health concerns? *Urgent, I think about it dailyModerate, I think about them but don't know enough to changeLow, I want to change but i'm not sure i'm readyWhat is your level of commitment to fixing your health concern? Scale of 1-10.When was the last time you faced a difficult situation and worked through it? *Please explain.Anything else you would like to share? *Anything, about your health or concerns, that would be beneficial for me to know.What does your ideal body and healthy life look like? Please explain. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: There was an issue loading your exit LeadBox™. Please check plugin settings.