Confidential Health History Form Page 3
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5LIFESTYLE
How is your diet? Please include food cravings and dietary restrictions, sensitivities or allergies
How much water do you intake per day:
Do you Use:
Now
Past
For how long? Type
Frequency
Tobacco
Alcohol
Caffeine
Soft Drinks
Recreational Drugs
Do you Exercise?
Yes
No
Number of times/ week: ___________, Type: ____________
Women Only:
Are you trying to conceive?
Yes
No
Are you pregnant now?
Yes
No
Form of birth control: ________________________________________________________________
Where are you in your menstrual cycle today? _______________________________________
Does your period cause you pain or cramping?
Yes
No
When?
Before
During
After Period
Pregnancies (please include losses and terminations):
Year
Vaginal or C section
Complications or conditions of note
____________________________________________________________________________________
____________________________________________________________________________________
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The Barefoot Dragonfly•11673 Jollyville Rd, Suite 201 • Austin, TX • 78759 • 512-666-9374 •
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