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.

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women's Wellness Survey