Health History Form Women - The Plant Priority

Making plants a priority on your plate
and for our planet

Women's Health History Form

Name *

First

Last

Today's Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Best Phone Number *

Birth Date *

Age *

Current Weight *

Weight one year ago? *

Would you like your weight to be different? *

If so, how?

Relationship Status *

What type of home do you live in? House, condo, apartment, etc. *

Any Children? Sex and ages? *

Any Pets? *

Occupation and how many hours a week? *

What are your main health concerns? *

Any addictions? Past or present? *

What do you do to deal with stress in your life? *

Do you meditate? *

What are 3 goals you would like my help with? *

At what age in your life did you feel the best? What do you think contributed to this? *

Current or previous serious illnesses? *

Current or previous serious injuries? *

What is your ancestry? *

Do you now have an active spiritual/religious practice? Did you as a child? *

Your mother's health is/was? *

Your father's health is/was? *

What is your blood type?

How many hours of sleep do you get most nights? *

Describe your sleep quality. Examples: Is your sleep broken? Do you have insomnia? Do you wake up to use the bathroom? Do you snore? Do you have sleep apnea? Do you wake up early and can't get back to sleep? Do you sleep with a partner or pets? Do you feel too hot or too cold? *

Describe the room you sleep in. Examples: What is the room temperature? Do you have a comfortable bed and linens? Does your pillow provide the right amount of support? Is your room light or dark? Do you hear noises from neighbors/kids/pets that keep you awake? *

Do you have pain or swelling upon awakening? *

Do you watch tv or are you on your cell phone or computer within 2 hours of going to bed? *

How do you feel upon awakening? Great/well rested, groogy, tired? *

How would you describe your cognative function? *

Do you have any digestive issues such as gas/bloating, constipation, diarrhea, ulcers or acid reflux? *

Do you have food allergies or sensitivities? *

Are your periods regular? How many days is your flow? Days between periods? *

Are your periods painful or have you been diagnosed woth PMS and/or PCOS? *

Have you reached or are approaching menopause? *

What is your birth control history? *

Do you experience urinary tract or yeast infections? If so, have you noticed what may trigger them? *

List all medications you are on or have been prescribed in the last 2 years, even if you are not taking them. *

List all supplements and dosages you take. *

Are there other practioners that you go to to find releif of your symptoms? Massage, chiropractic, acupuncture etc.? *

Do you exercise? Are you on a sports team? Describe your activity level. Are there physical activities you would like to do, but don't? Why? *

Will your family/partner/friends be supportive of your desire to make lifestyle and food changes? *

Do you cook? *

What percentage of your food is cooked at home? *

Where does your non-home cooked food come from? *

What was a typical breakfast as a child? *

What was a typical lunch as a child? *

What was a typical dinner as a child? *

Typical snacks and liquids as a child?

A typical breakfast now? *

A typical lunch now? *

A typical dinner now? *

Typical snacks now? *

Liquids: How many ounces of pure water, soda/pop, coffee, tea and alcohol do you consume on a daily basis now? *

Do you have cravings? Coffee caffeine, cigarettes? *

Do you do other drugs recreationally or to self-medicate for anxiety or stress? *

Name the 3 most important things you know you need to do to improve your health? *

Anything else you would like me to know? Example: Are you in an abusive relationship? Do you have toxic friends? Are you about ready to quit your job? Did you just get married, have a baby or get a new puppy?

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Making plants a priority on your plate and for our planet

Making plants a priority on your plate
and for our planet