Be Healthy Now
Spirituality, Relationships, Physical Activity, Career

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Eileen Weilbacher


Health Counselor
(631) 775-6196




Want to know more about
my training? Check out:
Institute for
Integrative Nutrition
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Spirituality, Relationships, Physical Activity, Career


Women's Health History Form

Personal Information

Name:
Address:
Email:
How often do you check mail:
Home Phone:
Work Phone:
Cell Phone:
Age:
Height:
Birthdate:
Place of Birth:
Current Weight:
Weight six months ago:
One year ago:
Would you like your weight
to be different:
If so, what?:

Social Information

Relationship status:
Children?:
Occupation:
Hours of work per week:

Health Information

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?:
How many hours?:
Do you wake up at night?:
Why?:
Any pain, stiffness or swelling?:
Constipation/Diarrhea/Gas?:
Are your periods regular?:
How many days is your flow?:
How frequent?:
Painful or symptomatic?:
Please explain:
Birth control history:
Vaginal infections,
reproductive concerns?:

Medical Information

Do you take any supplements
or medications?:
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?:

Food Information

What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What’s your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
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?:

Additional Comments

Anything else you would like to share?:





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Eileen Weilbacher 11 Wilson Street Rocky Point, New York 11778