Wise and Well Woman
Client Health History
Name
Birthday
Age
Height and Weight
Address
Email
Phone Number
Tell me about your main health concerns.
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What are your main concerns with your menstrual cycle?
How long have you had your symptoms?
What have you tried before to help your symptoms? ie:birth control, diets, etc
Have you had any recent health tests/blood work?
General Energy What is your energy like throughout a typical day. Include energy levels upon waking, sleeping, just after eating and several hours after eating, especially any notable peaks and falls during the day.
Diet What do you eat on a typical day? Please share breakfast, lunch and dinner along with snacks.
How is your appetite?
Do you eat 3 meals a day?
Are you hungry at breakfast or do you typically skip it?
After you eat, how long do you generally stay full?
Do you crave any foods (sugar, salt caffeine)?
How much water do you drink?
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1. What supplements do you take? 2. What medications do you take + dosages?
Bowels/Urination 1. How often do have a bowel movement?
Are they loose, formed, hard etc?
What color are they?
Is there any pain? If so how long have you had it?
Bloating, discomfort, belching or flatulence? If so how long have you experienced this?
How often do you urinate and what color is your urine?
Physical Pain 1. Do you experience any pain or aches in areas of the body. Please explain the location, general nature, and if it is constant, throbbing, or comes and goes.
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How long have you had this pain?
Stress/Emotional Health How are your emotions generally (i.e. balanced, fluctuating, depressed, etc.)?
Are there any specific emotions you experience more often?
What area in your life do you struggle with most?
4. Are you a perfectionist in any area (or all areas) of your life?
5. Do you feel anxious or overwhelmed? How often?
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What’s weighing you down?
Does stress manifest itself physically do you feel pain anywhere because of it (back, neck shoulders for example)?
Sleep How is your sleep? Are you tired when it is time to go to bed? Do you feel rested and awake when you wake up in the morning?
Do you sleep a full night without waking? If you do wake up, what time is it? Do you fall back to sleep easily?
Do you have night sweats?
Exercise 1. Do you exercise? 2. If so, how much do you do and what do you do?
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Do you enjoy exercising?
Menstruation/Fertility 1. How long is your cycle: 2. How long is your period:
Physical symptoms you experience leading up to and during your period (Nausea/PMS/Breast tenderness, diarrhea or bloating etc):
Emotional symptoms you experience leading up to and during your period (anxiety, depression, anger, moodiness, snappy etc):
Color and consistency of period (i.e. begins dark or light, tapers off or ends suddenly, any clotting):
Is there any pain, and if so explain the nature and if it gets better with warmth or pressure:
How much time do you spend dealing with or worrying about these issues?
What will your life look like once you address your specific health issues?
How much time have you had to take off from work or school in the last year? ∙ 0 to 2 days ∙ 3 to 14 days ∙ more than 15 days
What is your sex drive like? Do you think it can improve?
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Do you or have you ever had Urinary tract, yeast or bacterial infections?
Please share your menstrual/fertility history – any surgery, births, IVF, assisted conception, etc.
History Have you lived or traveled outside of the United States? If so, when and where? (I’m mostly concerned with places that may not have had clean drinking water):
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses in life? If so, please comment
Have any other family members had similar problems or conditions to what you are experiencing now?
How often did you take antibiotics as a child, teen and adult?
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General 1. What other practitioners are you currently seeing? (for example: therapist, naturopath, functional medicine doctor, massage therapist, bodywork practitioner, regular MD, etc)
2. Do you drink? If so, how much and when?
3. Do you smoke?
4. Is there anything else you’d like to share?
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