Women's Health Form

Name *

First

Last

Email *

How often do you check e-mail?

Home Phone

Work Phone

Mobile Phone

Age

Height

Birthdate

Place of Birth

Current Weight

Weight Six Months Ago

One Year Ago

Would you like your weight to be different? If so, how?

Relationship Status

Where do you currently live?

How many children?

Pets?

Occupation

Number of hours you work per week?

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? Of so, please list?

Any healers, helpers or therapies with which you are involved? Please list?

What role do sports and exercise play in your life?

What foods did you eat often as a child?

Breakfast, Lunch, Dinner, Snacks and Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

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 and Liquids

Additional Comments

Women's Health Form

WELLNESS WITH WALLY