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Copy of Market Square Graphics-5.png — HEALTH FORMS

If you have already scheduled a consultation or are an existing client, click the links below to fill out your Health History or Revisit Form.

WOMEN’S HEALTH FORM

New Form

PERSONAL INFORMATION

Name

First Name

Last Name

How often do you check your email?

Not Often

Average

Very Often

Home Phone

Work Phone

Mobile Phone

Age

Height

Birthdate

YYYY

Place of Birth

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different?

Desired Weight?

SOCIAL INFORMATION

Relationship status:

Single

In a Relationship

Married

Where do you currently live?

Children:

Pets:

Occupation:

Hours of work per week

HEALTH INFORMATION

Please list your main health concerns:

Other concerns and/or goals?:

At what point in your 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?:

How is your sleep?:

How many hours do you sleep?

Do you wake up at night?:

Yes

If yes, why?

Any pain, stiffness or swelling?:

Constipation/Diarrhea/Gas?:

Allergies or sensitivities? Please explain:

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:

MEDICAL INFORMATION

Do you take any supplements or medications? Please list:

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

What role do sports and exercise play in your life?:

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids

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

Do you cook?:

What percentage of your food is home-cooked?:

Where do you get the rest from?:

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

The most important thing I should do to improve my health is:

What is your food like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

ADDITIONAL COMMENTS:

Anything else you would like to share?:

Name

First Name

Last Name

REVISIT FORM

New Form

PERSONAL INFORMATION

Name

First Name

Last Name

HEALTH INFORMATION

What positive changes have you noticed since your last session?

What are your main concerns at this time?

Any changes with weight?

How is your sleep?

Constipation or diarrhea?

How is your mood?

FOOD INFORMATION

Are you cooking more?

What foods do you crave?

What is your diet like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

ADDITIONAL COMMENTS

Anything else you would like to share?

Name 1

First Name

Last Name

WOMEN’S HEALTH FORM

REVISIT FORM

INSTAGRAM

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