HEALTH HISTORY FORM Name * First Name Last Name Email * Phone (###) ### #### Age Birthdate MM DD YYYY Height and Weight (if you feel comfortable sharing): How did you find me? Option 1 Option 2 Main Health Concerns? Tell me about your current health situation along with concerns about your menstrual cycle or reproductive health. * How long have you had symptoms? On a scale of 1-10 (10 being worst) how severe are your symptoms? What have you tried in terms of treatment, or what are you considering? Be as detailed as you can be. How would you like your menstrual or reproductive health to be? How would you like your overall health to be? If you have had blood work or any other testing done, please specify here and email results to richellewcannon@gmail.com, if appropriate. I am mainly looking for hormone testing you may have done. Do you currently follow a specific diet? (Paleo, vegan, vegetarian, keto/low carb, etc? If you follow a specific diet, why did you decide to try it? How long have you been doing it? Do you track calories, macros or weigh your food? Have you noticed any changes in your health or symptoms (positive or negative) since the beginnng of this diet? Meals: What do you eat on a typical day? Please share breakfast, lunch and dinner , along with snacks. Breakfast: Lunch: Dinner: Snacks: Beverages (coffee, tea, soda, etc): Anything else you would like to share about your daily food intake? Appetite: How is your appetite? Do you eat three meals a day? If not, how many meals do you have? Are you hungry for breakfast or do you typically skip it? After you eat, how long do you generally stay full? Do you crave any foods or beverages (e.g. sugar, salt, caffeine) after you eat? Do you crave any foods or beverages (e.g. sugar, salt, caffeine) at any time in the day? How much water do you drink? Does your appetite change significanlty during the different phases of your cycle? For instance, are you extremely hungry in the lead up to your period and not so hungry after your period ends? Supplements/Medications: What supplements do you take (please list brands and dosage if available)? How long have you been taking these supplements? Are you taking these supplements uder the supervision of a physician or other healthcare professional? If you take medications, which ones do you take + dosages? How long have you been taking these medications? If you take medication, are you doining it under the superviosion of a physician? What kind of doctor? Bowels/Urination: How often do you have a bowel movement? Are the loose, formed, hard, etc? Please take a look at this chart and share which image your bowel movements most resemble. If you are constipated or have diarrhea, how long have you experienced this? https://www.webmd.com/digestive-disorders/poop-chart-bristol-stool-scale What color are they? Is there any pain? If so, how long have you had it? Bloating, discomfort, belching, flatulence? If so, how long have you experienced this? How often do you urinate and what color is your urine? Are there any problesm- pain, difficulty starting and stopping, etc? Physical Pain- Do you experience any aches or pains in the areas of the body? Please explain the location, general nature, and if it's constant, throbbing, comes and goes. How long have you had this pain? Stress/Emotional Health: How are your emotions generally )i.e. balances, fluctuating, depressed, etc.)? Are there any specific emotions you experience more often? Is there a time of the month when you notice certain emotions? Do you know if they correlate to your cycle? For instance, do you feel anxious or depressed a few days before your period? What area in your life do you struggle with most? Are you a perfectionist in any area (or all areas) of your life? Do you feel anxious or overwhelmed? How often? What's weighing you down? Does stress manifest itself physically- do you feel pain anywhere because of it )back, neck, shoulders, for example), stomach aches, headaches, etc? If you feel comfortable sharing, did you experience childhood trauma (abuse, neglect, abandonment, violence, etc)? Are you currently in a romantic relationship? If so, how is it going? Do you have supportive relationships in yout life? E.g. Are your parents supportive of you , do you have solid friendships, and is your partner supoprtive? Was there a time in your life when your emotional health suffered? E.g. burout, job stress, death in the family, etc. What is your energy like throughout a typical day? Include energy levels upon waking, sleeping, just after eating and several hours after eating, especially any notable peaks and falls during the day. Do you feel tired 1-2 hours after a meal? DO you have energy crashes mid-morning or mid-afternoon? Or at any other time of the day? If you experience energy crashes, what do you do to help them? (Coffee, sugar, naps, exercise etc) Was there a time in your life when you felt you had great energy or you felt really good? If so, please describe. What time do you tyically go to bed? How many hours of sleep are you averaging a night? Are you tired when it is time to go to bed? Or do you feel wired? Do you get a full night sleep without waking? If you do wake, what time is it? Do you fall back to sleep easily? Do you feel rested and awake when you wake in the morning? Do you have night sweats? Do you have sleep issues at certain times in your cycle? if yes, please describe. Do you exercise? If so, how many times are you exercising each week? What type(s) of exercise do you do? Do you enjoy exercising? How do you feel during and after exercise? (Energized, upbeat, tired, exhausted, etc?) Do you exercise according to your cycle? For example, do you do more strenuous exercise during your fillicular phase and ovulation versus in the lead up to your period? On average, how long is your entire menstrual cycle (from day one of your period to the day before your next period)? If it is irregular, please share the length of the last four cycles. How long is your period (actual flow- not including spotting)? Do you experience spotting before or at other times during your cycle? Briefly describe. What physical symptoms do you experience leading up to and during your period (nausea/PMS?Breast tenderness, spotting, diarrea or bloating etc) ? What emotional symptoms do you experience leading up to and during your period (anxiety, depression, anger, moodiness, snappy, etc)? What is the color and consistency of your period (i.e. begins dark or light, tapers off or ends suddenliy, any clotting)? Is there any pain with your period or ovulation, if so explain the nature and if it gets better with warmth or pressure or some treatment like medication? Are there any other symptoms associated with your cycle that you want to share? What do you see when you visualize your reproductive system? How much time do you spend dealing with or worrying about these issues? How much time (if any) have you had to take off work or school in the last year because of your health issues? What will your life look like once you address your specific health issues? What is your sex drive like? Has it changed recently? Do you think it can improve? Do you or have you ever had urinary track, yeast or bacterial infections? Please share your menstrual/fertility history- any surgery, births, IVF, assisted conception, etc? Do you experience acne? If so, does it correlate with specific times in your cycle? Do you experience any other skin issues (psoriasis, eczema, hives, etc)? If so, do they correlate with specific times in your cycle? Are you on hormonal birth control? If so, what are you using (pill, patch, nuvaring, depo shot, etc). If you are not on hormonal birth control, were you ever in the past? Please share how long you were on it for and why you went on it (for birth control, period pain, irregular cycles, acne etc). What form of birth control are you currently using if you are not on hormonal birth control? What kind of period protection products do you use? If you use pads or tampons, are they made of organic cotton? HAve you ever lived or traveled outside of your home country? If so, when and where? ( I am mostly concerned with places that may not have clean drinking water). HAve you or your family experienced any major life changes? If so, please comment. Have you experienced any major upheavals or losses in life? If so, please comment. Have any other family members had similar problems or conditions to what you are experiencing now? For instance your mom or grandmother had PCOS or endometriosis. How often did you take antibiotics as a child, teen and adult? Were you often sick as a child or teenager? If so, please elaborate. Have you had any surgeries? If so, what did you do and when? Have you ever lived in a house with mold or are you currently living or working in an environment with mold? Or do you suspect you did previously or do you currently? (Some ways to know this are flooding or water damage in your house, seeing actual mold, mustly smells in any part of your house, or living in a damp climate/environment). Mental Health- Mental Health/Eating Disorders/Diagnosis- Please list Current, Past, Date of OnSet Depression Yes No If yes, please list: Current, Past and Date of Onset Bipolar Disease Yes No If yes, please list: Current, Past and Date of Onset Anxiety Yes No If yes, please list: Current, Past, and Date of Onset PTSD Yes No If yes, please list: Current, Past and Date of Onset Schizophrenia Yes No If yes, please list date of onset Anorexia Yes No If yes, please list: Current, Past and Date of Onset Bulima Yes No If yes, please list, Current, Past and Date of Onset Binge Eating Disorder Yes No If yes, please list: Current, Past and Date of Onset Other Eating Disorder Yes No If yes, please list: Current, Past, Date of Onset Orthorexia Yes No If yes, please list: Current, Past and Date of Onset Disordered Exercise Yes No If yes, please list: Current, Past and Date of Onset Mental Health- Childhood & Environmental Factors Check all that apply to your chilhood/birth to your knowledge: Grew up in a city Born vaginally Traumatic Birth I was born premature I grew up in a home with domestic violence I took medications as a child regularly I had frequent ear infections or tubes I was abused (emotional/physical/sexual) Grew up feeling I didn't belong in my family My family had financial hardships My family had difficulty keeping food in the house I was primarily breastfed I was a full term baby I experienced physical abuse in my home I was sexually abused as a child Grew up on a farm Born via C-Section Mother died or was harmed during labor I was sick a lot as a child I grew up in a home with a parent who was addicted to alcohol or drugs I had frequent strep as a child I suffered TBI/concussions as a child Grew up in a household with frequent screaming My emotional needs weren't met I was asked to care for younger siblings What other practitioners are you currently seeing? (for example: therapist, naturopath, functional medicine doctor, massage therapist, bodywork practitioner, regular MD, etc) What type of practitioners have you seen in the past? Do you drink alcohol? If so, how much and when? Do you smoke cigarettes, cannabis or vape? Do you use or have you used any other illegal drugs? If so, which ones and when? Do you filter your drinking water? If yes, what kind of filter do you use? What kind of cleaning products do you use in your home? (Eco- friendly, conventional, etc) What kind of personal care products do you use ? (Makeup, haircare, body wash, etc). Are they eco- friendly or conventional brands? List the brands if you're not sure. Is there anything else you would like to share with me? Thank you!
