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Success Stories
Corporate Wellness
Telehealth Services
About Us
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Nutrition and Functional Medicine
Stephanie’s Story
Shop
Resources
Podcast
Ultimate Guide to Stress and Weight Loss
Ultimate Guide to Immune Health
Ultimate Guide to Detoxification
Blog
Detoxification
Food for the Mind
Nutrition and Wellness
Recipes
Weight Loss Tips
Contact
Get A Free Call
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Home
Signature Programs
Individual Programs
Elite Testing + Analysis
Success Stories
Corporate Wellness
Telehealth Services
About Us
Integrative Health + Nutrition
Nutrition and Functional Medicine
Stephanie’s Story
Shop
Resources
Podcast
Ultimate Guide to Stress and Weight Loss
Ultimate Guide to Immune Health
Ultimate Guide to Detoxification
Blog
Detoxification
Food for the Mind
Nutrition and Wellness
Recipes
Weight Loss Tips
Contact
Menu
Home
Signature Programs
Individual Programs
Elite Testing + Analysis
Success Stories
Corporate Wellness
Telehealth Services
About Us
Integrative Health + Nutrition
Nutrition and Functional Medicine
Stephanie’s Story
Shop
Resources
Podcast
Ultimate Guide to Stress and Weight Loss
Ultimate Guide to Immune Health
Ultimate Guide to Detoxification
Blog
Detoxification
Food for the Mind
Nutrition and Wellness
Recipes
Weight Loss Tips
Contact
Login
Charm-Personal Transformation Portal
Solaris 365 Desktop App
Solaris 365 Android App
Solaris 365 Iphone App
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Charm-Personal Transformation Portal
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Get A Free Call
Take Our Free Quiz
01. Women's Confidential Health History
Step
1
of
6
16%
Please complete this form in one sitting. Incomplete forms cannot be saved.
Name
*
First
Last
Date of Birth
*
Month
Day
Year
Today's Date
*
Month
Day
Year
Address Line 1
Address Line 2 (optional)
City
State
Zip Code
Email Address
How often do you check your email?
--
Every day
Several times a week
Once a week or less
Never
Telephone (work)
(home)
(cell)
Age
Height
Place of Birth
Current Weight
Weight 6 Months Ago
One Year Ago
Would you like your weight to be different?
Yes
No
What is your ideal weight?
Relationship Status
Children?
0
1
2
3
4
5
6
7
8
9
10+
Occupation
Hours of Work per Week
Please list your main health concerns:
Other concerns?
Any serious illnesses/hospitalizations/injuries?
How is the health of your mother?
How is the health of your father?
What is your ancestry?
What blood type are you?
Do you sleep well?
Yes
No
Why?
How many hours?
Do you wake up at night?
Yes
No
Why?
Any pain, stiffness or swelling?
Are your periods regular?
Yes
No
How many days is your flow?
How frequent?
Painful or symptomatic?
Painful
Symptomatic
Please explain:
Birth Control History?
Vaginal infections, reproductive concerns?
Constipation/Diarrhea/Gas?
Yes
No
Explain:
Do you take any supplements or medications?
Yes
No
Please list:
Any healers, helpers, pets or therapies with which you are involved?
Yes
No
Please explain:
What role do sports and exercise play in your life?
What foods did you often eat as a child?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
What's your food like these days?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
What percentage of your food is home cooked?
Where do you get your other food from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Anything else you would like to share?
Additional Contact Information
Gym (of which you are a member and location):
Client Consent for Release of Information
I hereby give Solaris Whole Heath my permission to release Medical Information to:
Name of Primary Care Physician
Physician Phone
Physician Address Line 1
Physician Address Line 2 (optional)
City
State
Zip Code
Date
Month
Day
Year
