Confidential Health History Form – Women Name and AddressFull Name Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryContact InformationEmail Phone Health HistoryDate of Birth Height Current Weight Weight 6 months ago Weight one year ago Would you like to change your weight? If so, what would be your desired weight? Relationship Status Do you have children? What is your occupation? What are your main health concerns? Any additional concerns? Any Serious Illness / Hospitalizations / Injuries ? How is the health of your Mother? How is the health of your father? What is your ancestry? What blood type are you? Do you generally sleep well ? How many hours do you sleep per night? Do you wake up during the night? If so, for what reason? Pain Stiffness or Swelling? Please identify any areas where you experience chronic pain or other symptomsReproductiveDo you experience regular menstrual periods? How many days is your flow? How frequent? painful or symptomatic? Please explain Birth control history Please list any current or past birth control methods usedInfections or other concerns? Any history of vaginal infections or other reproductive concerns?Constipation / Diarrhea / Gas? Please list any regular digestive symptoms or conditionsMedications / Supplements Do you take any supplements or medications? Please list:Therapies Any healers, helpers, pets or therapies with which you are involved? Please list:What role do sports and exercise play in your life? Describe your current dietBreakfast Lunch Dinner Snack Liquids What percentage of your food is prepared at home? Please list non-home-cooked food sources Do you crave sugar, coffee, cigarettes, or have any major addictions? Please share any additional relevant information. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: