Balanced Wellness Consulting | Confidential Health Form

Women’s Confidential Health History

Please write or print clearly and fax to: 631.204.6664

Important information we need to know:

First Name

Last Name

Address

How often do you check email?

Add answer here

Work Phone

Telephone:

Home Phone

Cell Phone

Your details:

Age

Height

Date of Birth

Place of Birth

Current Weight

Weight 6 Months Ago

One Year Ago

Would you like your weight to be different?

If so, what?

Relationship status

Children

Pets

Occupation

Hours of work per week

List your main health concerns

Other concerns and/or goals?

At what point in 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?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, swelling?

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:

Add answer here.

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

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

Add answer here.

What role does sports and exercise play in your life?

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What’s your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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

Add answer here

Do you cook?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

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

Add answer here

Anything else you want to share?