Women's Health History Form Name:Address:Multi Field is disabled in the free version frontendMulti Field is disabled in the free version frontendMulti Field is disabled in the free version frontendMulti Field is disabled in the free version frontendMulti Field is disabled in the free version frontendMulti Field is disabled in the free version frontendChildren:....Name(s) & Ages(s).... Health Issues.... Multi Field is disabled in the free version frontendWhat is your Primary health concern?What is your secondary health concern?What are you top 3 HEALTH GOALS?Multi Field is disabled in the free version frontendPlease describe all serious illnesses/hospitalizations/injuries, date, durationDigestive Symptoms: Heartburn, GERD, Bloating/Gas, Constipation, IBSMulti Field is disabled in the free version frontendChronic Headaches or Migraines?Multi Field is disabled in the free version frontendJoint or back pain, stiffness or swelling? Where? Severity? Frequency? Duration?Multi Field is disabled in the free version frontendMulti Field is disabled in the free version frontendWhat symptoms?Are you post-menopause? Y/NMulti Field is disabled in the free version frontendAre you experiencing hot flashes and/or night sweats?Are your cycles painful? Do you feel emotionally stressed before or during your cycles?Birth control history & current use:Multi Field is disabled in the free version frontendFrequency?Current medication(s) or supplement(s), Name, Brand, Purpose, Dosage & Frequency:Multi Field is disabled in the free version frontendMulti Field is disabled in the free version frontendName(s) and types of current healthcare providers, ie,Primary Care, Chiro,:etcType(s) of Exercise? How Long? How many times per week?How many hours spent outdoors in the sunshine per week?How many hours spent relaxing, reading, writing, listening to music or meditating per week?Multi Field is disabled in the free version frontendMulti Field is disabled in the free version frontendWhat foods do you usually choose? Breakfast Lunch Dinner Snacks LiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes?Multi Field is disabled in the free version frontendWhere do you get the rest from?o you crave sugar, coffee, cigarettes/ vaping, or alcohol? Any other biochemical dependencies?What is the most important change that would help you create a healthier lifestyle?Do you think that you could make better choices over time if you knew WHAT would help you get healthier?How do you think you would benefit from science-based EDUCATION, SUPPORT and GUIDANCE that would teach you how REGAIN and MAINTAIN your physical health and happiness?Is there anything else that you want to share?ReCaptcha is disabled in the free version frontendSend to Medea This form was created by ChronoForms
