Men’s Health History Questionnaire
Women’s Health History Questionnaire
Women’s Health History
All of your information will remain confidential.
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Place of Birth
How often do you check email?
What is your current weight?
How much did you weight six months ago?
How much did you weight a year ago?
What is your desired weight?
What is your relationship status?
Where do you live?
How many children do you have?
Do you have pets? If yes, how many and what kind?
How many hours do you work each week?
What are your main health concerns?
Do you have any other health concerns and/or goals?
At what point in your life did you feel best?
Have you ever experience 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 is your blood type?
How would you rate the quality of your sleep?
On average, how many hours do you sleep per night?
How often do you wake up at night?
Do you suffer any recurring pain, stiffness or swelling?
How frequently do you have constipation, diarrhea, and gas?
Please describe any allergies or sensitivities.
Are your periods regular? If not, how frequent are they?
How many days does your flow last?
Are they painful or symptomatic? If so, please explain.
Have your reached or are you approaching menopause?
Are you on birth control now? If so, for how long?
Do you experience frequent yeast infections or urinary tract infections? If so, please explain your symptoms.
Please list any supplements or medications you are taking.
Please describe any healers, helpers or therapies you are involved with.
What role do sports and exercise play in your life?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
How often do you cook your own meals?
About what percentage of your food is home-cooked?
Where do you get the rest from?
How would you describe your cravings for sugar, coffee, cigarettes? Do you have any major addictions?
The most important thing I should do to improve my health is?
What was your diet like as a child?
What is your diet like these days?
Anything else you would like to share?
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