Women's Health Care Evaluation - Root Down Rise Up Health & Nutrition Consulting

Personal Information

Name

First Last

Email

Phone - Home

Phone- Work

Phone - Mobile

General Information

Age

Height

Place Of Birth

Birthdate

Current Weight

Weight six months ago

One Year Ago

Would you like your weight to be different?

If so, what?

Social Information

Relationship Status

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 of 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 ancestory?

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain stiffness or swelling?

Constipation / Diarrhea / Gas?

Allergies or sensitivities?

Women's Health

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 roles do 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?

What percentage of your food is home-cooked?

Where do you get the rest from?

Do you cook?

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

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

Additional Information

Anything else you would like to share?

Women’s Health Care Evaluation

Please fill out the form below to the best of your ability.

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General Information

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Health Information

Women's Health

Medical Information

Food Information

Additional Information

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Women’s Health Care Evaluation

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General Information

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Health Information

Women's Health

Medical Information

Food Information

Additional Information

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