Julian Christopher Cortez, M.Ed., M.A.
Holistic Health
Practitioner
Women's Health History Form
Full Name
Address
Zip
Work Phone
Home Phone
Email
Age
Date of Birth
Place of Birth
Current weight
Weight six months ago?
One year ago?
Would you like your weight to be different?
Yes
No
If so, what?
Relationship status
Children?
Occupation
Blood Type
How many hours a week do you work?
Do you sleep well?
Yes
No
Do you wake up at nights?
Yes
No
What time(s)?
What time do you generally get up in the morning?
Constipation/Diarrhea
Are your periods regular?
Yes
No
How many days is your flow?
How frequent?
Painful or symptomatic?
Yes
No
Please explain
Do you take any vitamins/medications? If so, which?
Are there any other healers, helpers, pets, or therapies
with which you are involved? Please list
What role does exercise play in your life ?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked?
%
Where do you get the rest from?
How is the health of your father?
How is the health of your mother?
Serious illness / hospitalizations / injury
What is your chief health concern?
Other concerns?
What foods did you eat often as a child?
breakfast
lunch
dinner
snacks
liquids
What about a year ago?
breakfast
lunch
dinner
snacks
liquids
What's your food like these days?
breakfast
lunch
dinner
snacks
liquids
INTRO
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HOME
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PROGRAM
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BIOGRAPHY
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HEALTH HISTORY
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CLASSES
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TESTIMONIALS
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PRODUCTS
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RESOURCES
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CONTACT
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SITE MAP
Julian Christopher Cortez, M.Ed., M.A. | 6440 Palmetto Street - Ridgewood, NY 11385
