Women’s Health Questionnaire Name * First Name Last Name Email * Phone (###) ### #### Birth Date * Place of Birth Age Height Current Weight Weight Six Months Ago One Year Ago What is your desired weight Relationship status Shipping address 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 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? On average, how many hours do you sleep at night? 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? Please list Any healers, helpers or therapies with which you are involved? Please list: What role do sports and exercise play in your life? 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 DIGESTION SYMPTOMS Heartburn Bloated Feeling Diarrhea Constipation Stomach/intestinal pain Burping SKIN SYMPTOMS Acne Rashes Dry/Itchy Skin Hair Loss Cold Sores (Fever Blisters) Eczema MENTAL HEALTH Headaches Dizziness Insomnia Memory Issues Poor Concentration or Focus Brain Fog FEMALE HEALTH Irregular Menses UTI Yeast Infections Heavy Bleeding Decreased Libido OTHER SYMPTOMS Stuffy Nose Snoring Sinus Problems Sneezing Attacks Itchy Ears/Ear Infections Drainage from Ear ENERGY LEVELS Restlessness Hyperactivity Fatigue / Sluggishness Afternoon Energy Crash Describe your current dietary habits Electronic Signature Thank you!
