Women Health Forms and Information

Women's Health History Form

Name: Email Address :

Address:

How often do you check email?

Telephone Work: Home: Cell:

Age: Height: Date of Birth : Place of Birth :

Current Weight : Weight 6 months ago : 1 year ago :

Would you like your weight to be different? Yes No

Relationship Status: Number of Children:

Occupation: Hours of work per week:

Please list your main health concerns:

Other 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 sleep well? Yes No Sometimes

Do you wake up at night? Yes No Sometimes

How many hours? Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Please explain:

Do you take any supplememts or medicaitons? Please list:

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

What role do sports and exercise play in your life?

What foods did you often eat as a child?

What's your food like these days?

What percentage of your food is home cooked?
What percentage is not?

Where do you get the rest from?

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

Anything else you would like to share?

Bodnar Chiropractic Center: 6969 Richmond Highway, Alexandria VA 22306