Women's Healthy History NameFirstLastEmailHow often do you check email?Date of birthPlace of birthPhone NumberAgeHeightWeightWeight Six Months AgoWeight One Year AgoWhere do you currently live?Social InformationRelationship StatusOccupationChildrenYesNoPetsYesNoHealth InformationPlease list your main health concernsPlease list your main health concernsAt what point in your life did you feel your best?Any serious injuries or hospitalizations?What is the health of your mother and/or father?What is your ancestry?What blood type are you?How is your sleep?Do you wake up at night? If so, why?How many hours of sleep do you get?Allergies or sensitivities?Any pain, stiffness, or swelling?Constipation, diarrhea, or gas?Are your periods regular?How many days is your cycle?Painful or symptomatic?Reached or approaching menopause?Birth control historyDo you experience yeast infections, or urinary tract infections? Please explain.Medical InformationDo you take any supplements or medications? Please list.Any healers, therapies, or helpers with which you are involved in? Please list.What role does sports and exercise play in your life?Food InformationWhat foods did you often have as a child?What is your food habits like these days?Will family and freinds be supportive of this lifestlye change?YesNoNot sureDo you cook?YesNoWhat percentage of your food is home cooked?80% - 100%50% - 70%20% - 40%Where does the rest come from?Do you crave sugar, coffee, cigarettes, or any other major addictions?Are you a current cigarette smoker?The most important thing I should do to improve my health is?Additional comments?List any other important details you would like for me to know about yourself.