• Women's Health History Form

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  • Please write in your top 3 health complaints/ concerns inorder of importance to you. Check the items that make it better or worse and mark the severity of the condition on the scale from 1-5 (0=No symptoms, 5=worst ever)

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  • TEMPERATURE

    How warm/cold do you feel (not in degrees); relative to other people do you wear more or less clothing, etc.

     


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  • MOISTURE

    Your overall body moisture (hair, skin, mouth, etc.)


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  • DIGESTION

     


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  • ENERGY

     
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  • URINARY

     

  • MENSTRUATION

     

  • MENOPAUSE


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  • We greatly appreciate your time in filling out your healt history. . .it is the first step in enabling us to give you the most appropriate and high quality care that you expect from our clinic.

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