Women's Confidential Health History Thank you for filling out this form - it is essential in understanding your goals and medical history. Step 1 of 2 50% Name First Last Email Work PhoneHome PhoneCell PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country AgeHeightDate of Birth Place of BirthCurrent WeightWeight six months agoWeight one year agoWould you like your weight to be different?YesNoIf so, what?Relationship StatusChildrenPetsOccupationHours of work per weekPlease list your main health concernsOther concerns and/or goals?At what point in your life did you feel best?Any serious illnesses/hospitalizations/injuries?Please explainHow is/was the health of your mother?How is/was the health of your father?What is your ancestry?What is your blood type?Do you sleep well?YesNoHow many hours?Do you wake up at night?Why? Any pain stiffness or swelling?Are your periods regular?YesNoSometimes/Used to beHow many days is your flow?How frequent?Painful or symptomatic?Please explainReached or approaching menopause?Please explainBirth Control HistoryPlease share any and all birth control usedDo you take any supplements or medications?Please listConstipation/Diarrhea/Gas?Please explainAllergies or sensitivities?Please explainDo you experience yeast infections or urinary tract infections?Please explainAny healers, helpers or therapies with which you are involved?Please listWhat role does sports and exercise play in your life?Do you crave sugar, coffee, cigarettes or have any major addictions?What foods did you eat often as a child?Breakfast - Lunch - Dinner - Snacks - LiquidsWhat's your food like these days?Breakfast - Lunch - Dinner - Snacks - LiquidsWill family and/or friends be supportive of your desire to make food and/ore lifestyle changes?YesNoHope so, not sureYet to be determined - reluctantWeighs heavily on meWhat percentage of your food is home-cooked?Do you cook?Where do you get the rest of your food?The most important thing I should change about my diet to improve my health is:Anything else you want to share? Thank you for ALL your information. Your information will be kept confidential Spam controller - have a little fun now and then!PhoneThis field is for validation purposes and should be left unchanged.