Wednesday, November 28, 2007

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?:

















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