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Women’s Confidential Health History 

Please write or print clearly and fax to: 631.204.6664 

Important information we need to know:

How often do you check email?
 

Telephone:
 

Your details:
 

Do you experience yeast infections or urinary tract infections? Please explain:

Any healers, helpers or therapies with which you are involved? Please list:

What foods did you eat often as a child?
 

What’s your food like these days?

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

The most important thing I should change about my diet to improve my health is: