Womens Health Quiz Your Name:* First Last Your Email:* Home Phone:Work Phone:Mobile Phone: Height:Age:Birthdate: Place of Birth: Current Weight:Weight six months ago:Weight one year ago:Would you like your weight to be different?If you answered yes, what would you like your weight to be? Social InformationRelationship status:Where do you currently live?:Children:Pets:Occupation:Hours of work per week:Health InformationPlease list your main health concerns: Any pain, stiffness or swelling?: Other concerns and/or goals?: Constipation/Diarrhea/Gas?: At what point in your life did you feel best?: Allergies or sensitivities? Please explain: Any serious illnesses/hospitalizations/injuries?: Are your periods regular?: How is/was the health of your mother?: How many days is your flow?: How is/was the health of your father?: How frequent?: What is your ancestry?: Painful or symptomatic? Please explain: What blood type are you?: Reached or approaching menopause? Please explain: How is your sleep?: Birth control history: How many hours?: Do you experience yeast infections or urinary tract infections? Do you wake up at night? If so, why?: Medical InformationDo you take any supplements or medications?Any healers, helpers or therapies with which you are involved? Please list:What role do sports and exercise play in your life?:Food InformationWhat foods did you eat often as a child?What is your food like these days?Breakfast: Breakfast: Lunch: Lunch: Dinner: Dinner: Snacks: Snacks: Liquids: 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:Additional CommentsAnything else you would like to share?: PhoneThis field is for validation purposes and should be left unchanged.