PhoenixWay Women's Wellness Survey

Personal Information

* Indicates required field

Name *

Email *

Phone Number *

Age *

Date of Birth *

Place of Birth *

Address: Number & Street *

Address: City, State, Zip *

Relationship status *

Age and gender of partner *

Age and gender of children *

What kind of pets do you have? *

Health Information

Height *

Weight *

Weight 6 mos ago *

Weight 1 yr ago *

Ideal Weight *

At what point in your life did you feel best? *

Any serious illnesses or injuries? When? *

Describe any current medical or alternative treatments. *

List any medications or supplements you're taking. *

How was the health of your mother? *

How was the health of your father? *

How is your sleep? *

How many hours do you sleep on average? *

Describe any pain, stiffness or swelling. *

Describe any constipation, diarrhea, bloating or gas. *

How is your mood? Please describe. *

How is your anxiety? Please describe. *

Describe any allergies or sensitivities. *

Are your periods regular? *

How many days is your flow? *

Have you reached or are you approaching menopause? *

Painful or symptomatic? Please explain. *

Birth control medication history *

Do you experience UTIs or yeast infections? *

What are your main physical and/or mental health concerns at this time? *

Food Information

What foods did you eat often growing up?

Breakfast (past) *

Lunch (past) *

Dinner (past) *

Snacks (past) *

Late Night Snacking? (past) *

Liquids (past) *

What foods are you eating now?

Breakfast (now) *

Lunch (now) *

Dinner (now) *

Snacks (now) *

Late Night Snacking? (now) *

Liquids (now) *

Other Information

What is your occupation? *

Do you like it? *

Hrs / wk *

What kind of exercise are you doing? *

How frequently? *

How are things going in your spiritual practice? *

How are things going in your primary relationship? *

How are your relationships with family, friends, coworkers, clients? *

Will your family & friends be supportive of lifestyle changes you'd like to make? *

Describe any food, drug, or activity addictions you have. *

Describe what you want to improve most about your health. *

Anything else you'd like to add? *

Please note that all information submitted here is private, confidential, and protected by law. Please also note that the form will not successfully submit unless ALL required fields (marked with an asterisk) are completed.

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women's Wellness Survey