Skip to content

Email

[email protected]

Request Appointment

Welcome
About
Work With Me
Resources
Contact Me

Menu

Welcome
About
Work With Me
Resources
Contact Me

Women's Health
Discovery Form

Fill out the below form to tell me more about your past and present health, and your future goals.

All answers will remain confidential.

Name *

First

Last

Email: *

How often do you check your email? *

Mobile Phone: *

Home Phone:

Age: *

Height: *

Birthdate: *

Current Weight: *

Weight six months ago: *

Weight one year ago: *

Would you like your weight to be different? *

Yes
No

If yes, what?

Relationship Status? *

Married
Dating
Single
Complicated

Where do you currently live? *

Do you have children? *

Yes
No

If yes, how many?

Do you have pets? *

Yes
No

If yes, what kind & how many?

Please list your main health concerns: *

Other concerns and/or goals?

At what point in your life did you feel your best? *

Any serious illnesses/hospitalizations/injuries? *

How was/is the health of your mother? *

How was/is the health of your father? *

What is your ancestry? *

What blood type are you? *

How is your sleep? *

How many hours? *

8-9 Hours
7-8 Hours
6-7 Hours
5-6 Hours
Less than 5 hours

Do you wake up at night? If yes, why? *

Any pain, stiffness, or swelling? *

Any constipation/diarrhea/gas? *

Allergies or sensitivities? Please explain: *

Are your periods regular? *

Yes
No

How many days is your flow? *

How frequent are your periods? *

Painful or symptomatic? Please explain: *

Birth Control History: *

Do you experience yeast infections or urinary tract infections? Please explain: *

Do you take any medications or supplements? Please list: *

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

What role do sports and exercise play in your life? *

What foods did you eat often as a child for breakfast? *

What foods did you eat often as a child for lunch? *

What foods did you eat often as a child for dinner? *

What foods did you eat often as a child for snacks? *

What foods do you eat for breakfast now? *

What foods do you eat for lunch now? *

What foods do you eat for dinner now? *

What foods do you eat for snacks now? *

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *

Yes
No

Do you cook? *

Yes
No

What percentage of your food is home-cooked?

Selected Value: 0

Where do you get the rest from? *

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

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

Anything else you would like to share?

Contact Info

Email: [email protected]

Clinic Hours

Mon-Fri 9:30 am - 5:00 pm
Sat-Sun Closed

Quick Links

Welcome
About
Work With Me
Resources
Contact Me

Welcome
About
Work With Me
Resources
Contact Me

©2024,Wholisitc Health All Rights Reserved