Lisa Fabry Nutrition & Yoga Therapy
Client Information Form
General Health: Women
Date of birth
Phone number (inc country and area code)
Other medical practitioners you see
Do you have any current medically diagnosed conditions or injuries?
What are your three main health goals?
Has your weight increased or decreased in the last year?
How many drinks containing alcohol do you have per week?
Are you a smoker? If so, what do you smoke, how many and for how many years?
Please list all medication you take, including prescribed drugs, over-the-counter medicines and supplements.
Have you ever experienced a hypersensitivity reaction to any medication or remedy?
Do you have any known allergies or sensitivities?
FAMILY HEALTH HISTORY
PERSONAL HEALTH HISTORY
PLEASE DESCRIBE ANY SYMPTOMS YOU CURRENTLY HAVE
Anything else not mentioned?
Please list any significant events in your life, which could have impacted your health.
WOMEN: Reproductive and Sexual Health
Age of menarche (first period)
Do you currently have a menstrual cycle?
If you do currently have a menstrual cycle:
Are your periods regular or irregular?
How long is your usual cycle?
How many days does your period last?
Is your blood flow heavy/medium/light?
Do you see any clots in the blood?
What kind of sanitary products do you use?
If you do not currently have a menstrual cycle:
When was your last period (approximately)?
How many pregnancies have you had?
Have you had any miscarriages/ terminations?
Have you had any gyno surgeries? Please give details.
When was your last Pap smear?
When was your last breast exam?
Are you currently sexually active?
What kind of contraception are you using?
Do you suffer from UTIs or yeast infections?
Do you have experience of the following:
weight gain in midsection?
Do you have any concerns about your sexual health?