Women's Health History

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Personal Information

Would you like your weight to be different?

Yes
No



Social Information

Children

Yes
No

Pets

Yes
No



Health Information

Do yo u wake up at night?

Yes
No

Any pain, stiffness or swelling?

Yes
No

Constipation/Diarrhea/Gas?

Yes
No

Are your periods regular?

Yes
No



Medical Information



Food Information

What foods did you eat often as a child?


What is your food like these days?

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

Yes
No

Do you cook?

Yes
No

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

Yes
No

Would you like to subscribe to our newsletter?

Yes

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