Female Health History Questionnaire

Basic Info Today's Date: Full Name: Age: Birth Date: Weight: Height: Occupation: Email Address: Phone Number:

History 1. What is the reason for this visit? 2. List medications you are currently taking: 3. Date of last gynecological exam: Last Pap Test: Last mammogram:

Reproductive Health History 3. Are you, or have you used oral, injected, patch, or ring hormone contraceptives, or used Emergency Contraception (aka “the day after” pill)? Yes No If yes, which one, when and for how long? 8. Have you been pregnant before? Yes No

For Cycling-Age Women

(please fill in the appropriate answer)

3. How many days is your current cycle? (Counted from the first day of your period to the first day of your next period) 5. Is your cycle regular? Yes No Not Always Details: 6. Typical menstrual flow: Light Medium Heavy

Details:

8. Do you pass clots?

Yes No How often? 10. Do you experience cramping?

None
Mild
Moderate
Severe

At what point in your cycle?

For Menopausal Women

(please fill in the appropriate answer)

1. Your age at the onset of menopause: Year of onset: 2. Have you had a hysterectomy?

No
complete (ovaries AND uterus)
partial (uterus only)

6. Have you used, or are you currently using, conventional hormone replacement therapy (HRT)? Yes No If yes, what were you prescribed? What dosage? For how long?

7. Have you used, or are you currently using bioidentical hormone creams/gels/sublingual, troche, oral? Yes No If yes, what? What dosage? For how long?

Sleep Habits 1. How well do you sleep?

Well
Trouble falling asleep
Trouble staying asleep
Insomnia

How long has this been happening? 2. How many hours do you sleep a night on average? 3. Do night sweats wake you up? Yes No
If yes, how often? 4. Do you wake up tired? Yes No
How long has this been happening?

Signs and Symptoms

INSTRUCTIONS: Check either "Ongoing" or "Just w/ Period" for each problem that applies to you.

Check both if the problem is ongoing and worse with your period. Then rate the severity.

SIGNS & SYMPTOMS	ONGOING	JUST W/ PERIOD	Mild, Moderate, Severe?	MORE INFORMATION
Mood swings
Anxiety/Nervousness/Irritable
Overly Reactive/Short fuse/Anger
Depression
Low Blood Sugar/ High Blood Sugar
Lowered self esteem/self image
Caretake others before yourself
Sadness/Crying
Trouble concentrating
Memory difficulties
Fatigue/Anemia
Increased appetite/Constant hunger
Sweet cravings (carbs/chocolate)
Caffeine/Stimulant cravings
Salt cravings
Headaches/Migraines
Muscle pain/Joint Aches/Backache
Weight gain/Trouble loosing weight
Weight loss
Water Retention
Bloating/Belching/Gas
Stomach burning/Nausea/Indigestion
Constipation
Light colored stool
Loose stool/Diarrhea/IBS
Acne/Rashes/Bown spots
Excessive facial hair/Body hair
Body/Head hair loss
Infertility
Lowered libido
Heightened libido
Hot flashes/Night sweats
Palpatations
Breast tenderness/Cysts
Nipple discharge
Vaginal infections/Yeast infections
Urinary frequency/Incontinence
Dry eyes/Dry skin/Overall dryness
Change in Labial/Clitoral tissue
Vaginal changes (dryness, tearing)
Any other symptoms?