Women’s Health History

All information will remain confidential between you and Kelly Kurtz.

Personal Information

First Name (required)

Last Name (required)

Email (required)

How often do you check email?

Mobile Telephone

Home Telephone

Work Telephone

Age

Height (in inches)

Place of Birth

Current Weight

Weight six months ago

Weight one year ago

Would you like your weight to be different?

If so, what?

Social Information

Relationship status

Where do you currently live?

Children

Ages of Children

Pets

Type of 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 illness/ hospitalization/ 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 (per night)?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?
 Pain Stiffness Swelling

Where is the pain, stiffness, or swelling?

Constipation/ Diarrhea/ Gas?
 Constipation Diarrhea Gas

Allergies or sensitivities? Please explain:

Women's Health

Are your periods regular?

How many days in your flow?

How frequent?

Painful or symptomatic?
 Painful Symptomatic

Please explain:

Reached or approaching menopause?
 No Reached Approaching

Please explain:

Birth control history:

Do you experience yeast infections or urinary tract infections?
 No Yeast Infections Urinary Tract Infections

Please explain:

Medical Information

Do you take any supplements or mediations? Please list:

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

What role does sports and exercise play in your life?

Food Information

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What is 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?

Do you cook?

What percentage of food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarette, or have any major addictions?
 Sugar Coffee Cigarette Other

Other addictions:

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

Additional Comments

Anything else you would like to share?

 


Copyright © Institute for Integrative Nutrition, with some minor clarifying modifications by Kelly Kurtz.