Women’s Intake 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?: