Women’s Health History

Please take the time to complete this form with as much detail as you can. All of your information will remain confidential between you and me.

Name *
Address *
(this can be from any area in your life)
(please give as much detail as possible)
How many hours do you normally sleep? Do you wake up at night? How often? What is generally the reason?
Do you have any pain stiffness or swelling? *
Do you experience problems with constipation, diarrhea, or gas? *
Do you have periods? *
If yes, please explain.
Are you approaching menopause? *
Are you on / or have you ever been on hormone replacement therapy (HRT) *
Please check the box if you have/currently experience any of the following symptoms *
If yes, please list below.
If yes, please detail.
Please list at least one item for breakfast, lunch, dinner, snack and liquids.
Please list at least one item for breakfast, lunch, dinner, snack and liquids.
Do you cook? *
eg. home, work, anywhere, at night, during the day, with people, when you are alone.
Are family and friends supportive of your desire to make some lifestyle changes? *
Please review and check the box if you have any of the following condiitons *
Client Confidentiality and Agreement *
By ticking the box below: I understand the consultation is not a replacement for medical care. I understand the practitioner does not diagnose medical illness, disease or any other physical or mental conditions and does not prescribe medical treatment of pharmaceuticals. I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have. I have stated all my known conditions and take it upon myself to keep the practitioner updated on my health. I agree to give at least 24 hours notice of cancellation of appointment. I give my permission, for my practitioner to take notes about me, including health history/medical and /or personal information I choose to disclose to her. I understand this information may be used for the purpose of practitioner certification and/or may be shared with the Institute for Integrative Nutrition for statistical data collection only. All relevant identifying information will not be disclosed such as name, address, date of birth.

Thank you for taking the time to complete this form. I look forward to connecting with you.