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Health History Questionnaire

First Name Last Name
Age: Weight: Height:
Occupation:
E-mail
How did you learn about WomanAnew?

What is the reason for this consultation?

List medications you are currently taking:

Any known allergies?

List all the nutritional supplements, remedies, herbs and performance enhancement supplements you are currently taking:

List existing health problems(surgery, medical procedures):

List past health problems(surgery, medical procedures):

Lifestyle Habits

How do you rate your stress level ?(1=low, 10=very high)

How do you handle your stress? (1=poorly, 10=very well)

Do you use:

Alcohol - how much/often?
Cigarettes - how much/often?

Coffee - how much/often?

Soda - how much/often?

Refine carbs and/or sweets - how much/often?

Do you exercise? - how much/often?

Do you drink water? - how much/often?

Signs & Symptoms

 Depression
 Short temper
 Anxiety
 Nervousness
 Irritability
 Lowered self-esteem
 Crying
 Sadness
 Fatigue
 Foggy thinking
 Difficulty remembering
 Headaches
 Migraines
 Joint pain
 Back pain
 Weight gain
 Weight loss
 Water retention
 Constant hunger
 Sweet cravings
 Carbs craving
 Chocolate craving
 Caffeine craving
 Salt craving
 Bloating
 Gas
 Constipation
 Diarrhea
 Irritable Bowel
 Light colored stool
 Vomiting
 Nausea
 Excessive facial hair
 Head hair loss
 Dry skin
 Acne
 Brown spots
 Low libido
 Heightened libido
 Painful intercourse
 Vaginal dryness
 Night sweats
 Hot flashes
 Frequent urination
 Incontinence

(Your information is kept in the strictest of confidence and is only uses for your consultation)