Womens Health History

Please write or print clearly. All of your information will remain confidential between you and the Me.
PERSONAL INFORMATION
First Name:

Rama Abhista

Last Name:
Email:

Kotakonda

Abhista.k@gmail.com

How often do you check email?

Phone: Home:
Age:

Work:

27

Height:

Current weight:

164
cms

89

Birthdate:

Would you like your weight to be different?

Mobile:

15-07-1986

Weight six months ago:

yes

regularly

Place of Birth:
93

kakinada

One year ago:

If so, what?

93

Ideal weight

SOCIAL INFORMATION
Relationship status:
Where do you currently
live?
Children:
Occupation:

Married
Germany

Pets:
House wife

no
Hours of work per week:

HEALTH INFORMATION

Please list your main health concerns:

Integrative Nutrition

I want to reduce my weight so that I will not get any other

complications such as diabetes, blood pressure etc.

PAGE 2

Womens Health History

Other concerns and/or goals?

At what point in your life did you feel best?

When I play with my son in the park

Any serious illnesses/hospitalizations/injuries?

no

HEALTH INFORMATION (continued)

How is/was the health of your mother?

She is nearing 50 and having high BP

How is/was the health of your father?

He is 58 years old and diabetic

What is your ancestry?

How is your sleep?
Why?

Obese

Good

What blood type are you?

How many hours?

A+

Do you wake up at night? yes

I will go to washroom minimum once during night

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

no

no

Allergies or sensitivities? Please explain:

no

WOMENS HEALTH
Are your periods regular?

yes

How many days is your flow?

Painful or symptomatic? Please explain:

How frequent?

Stomach ache and occasionally back ache

Reached or approaching menopause? Please explain:

Integrative Nutrition

no

28 to 30 days

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Womens Health History

Birth control history:

I am using copper loop from 2012 nov which is for 3 years

Do you experience yeast infections or urinary tract infections? Please explain:

no

MEDICAL INFORMATION
Do you take any supplements or medications? Please list:

no

Any healers, helpers, or therapies with which you are involved? Please list: no

What role do sports and exercise play in your life?

Minor role

FOOD INFORMATION
What foods did you eat often as a child?
Breakfast
idli

Lunch
Rice and dal

Dinner
Rice curry and
curd

Snacks
Puffs and home
made snacks

Liquids
Milk , orange
juice and water

Dinner

Snacks

Liquids
Water,juices
and one cup
coffee or tea

dosa

What is your food like these days?

Breakfast
Idli,bread,dosa

Integrative Nutrition

Lunch
kichidi

Pulka with some

curry

biscuits

PAGE 4

Womens Health History

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?

yes

Where do you get the rest from?

What percentage of your food is home-cooked?

Night when I go to bed

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should do to improve my health is:

ADDITIONAL COMMENTS
Anything else you would like to share?

Integrative Nutrition

yes

I crave for cakes and pastries

Some physical activity and diet

90%