Health Assessment

Health Assessment - Women

To make a better use of our FREE initial consultation, please answer the following questions to the best of your abilities and provide information with which you feel comfortable. The information provided will be used as a guide to discover the areas in which more assistance is needed.

After completing the questionnaire, please remember to submit it along with your information. Thank you!

Health History - Women

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Place of Birth

Current weight

Weight six month ago

Would you like your weight to be different?

If so, what?

Relationship status

Children?

Pets?

Occupation

Hours of work per week

Please list your main health concerns:

Other concerns and/or goals?

At what point in your life did you feel the best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

How is your sleep? How many hours?

Do you wake up at night? If so, why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain.

Are your periods regular?

How many days in your flow?

How frequent?

Painful or symptomatic? Please explain:

Reached or approaching menopause?

Birth control history:

Do you experience yeast infections or urinary tract infections?

Do you take any supplements or medications? 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?

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?

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? What do you usually eat for breakfast, lunch, diner, liquids, and snacks?

Anything else you would like to share?

Please print your name & sign

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