Women’s Intake Form

Women’s Health History Form

Personal Information





Name:
Address:
Email:
How often do you check mail:
Home Phone:
Work Phone:
Cell 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, what?:

Social Information




Relationship status:
Children?:
Occupation:
Hours of work per week:


Health Information








Please list your main health concerns:
Other concerns?:
Any serious
illness/hospitalizations/injuries:
How is the health of your mother?:
How is the health of your father?:
What is your ancestry?:









What blood type are you?:
Do you sleep well?:
How many hours?:
Do you wake up at night?:
Why?:
Any pain, stiffness or swelling?:
Constipation/Diarrhea/Gas?:







Are your periods regular?:
How many days is your flow?:
How frequent?:
Painful or symptomatic?:
Please explain:



Birth control history:
Vaginal infections,
reproductive concerns?:


Medical Information




Do you take any supplements
or medications?:
Please List:





Any healers, helpers, pets 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





What’s your food like these days?
Breakfast

Lunch

Dinner

Snacks

Liquids





What percentage of your food is home cooked?:
What percentage is not?:
Where do you get the rest from?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?:


Additional Comments


Anything else you would like to share?:

Share tweet pin +1 back to top

Your email is never published or shared. Required fields are marked *

*

*

T w i t t e r
F a c e b o o k