Female Health Questionnaire

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Patient Information

First Name:
Last Name:
Date of Birth:
Today's Date:
Age:
Home Address:
Street Address:
Address Line 2:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Fax:
Other Address:
Street Address:
Address Line 2:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Marital Status:
Referred By:
Fax number (not phone number) of your favorite pharmacy:
Name of person to contact in case of an emergency:
Emergency contact's relationship to you:
Their phone number:
Your Primary Care Physician:
Their fax number:
Their phone number:

Medical 1

When did you last feel well?
Describe any symptoms, illness and/or health issues you are having now:
Describe any major symptoms, illness and/or health issues you have had in your past:
Regarding your health: what would you like most to accomplish?
On a scale of 0-10, with ten being the highest level you experienced, rate your:
Energy level:
Libido:
Mood:
Bowel movements:
Sleep:
Pain:
PAST MEDICAL HISTORY (Please specify):
CHILDHOOD
ADULT
Accident and/or injuries:
Hospitalizations:
Surgeries:
Immunizations:
SIGNIFICANT ILLNESS IN YOUR FAMILY:
Mother:
Father:
Maternal Grandfather:
Paternal Grandfather:
Maternal Grandmother:
Paternal Grandmother:
Daughter(s) or Son(s):
Other:
List any prescription medications you currently take (include strength and time[s] of day):
List any significant prescription medications you have taken in the past:
List any medications you are allergic to:
Estimate the number of days in your lifetime that you have taken antibiotics:

Medical 2

Describe any chronic or occasionally recurring pain:
Estimate:
Cups of coffee per day:
In past:
Number of cigarettes per day*:
In past:
Daily recreational drug use*:
In past:
Daily alcohol intake (what and how much)*:
In past:
(* = answer optional)
Describe any significant toxic exposure you have had (examples: pesticide, industrial, other):
Have you had your mercury amalgams removed?
Do you have any root canals?
             How many?
Do you have any dental implants?
             How many?
Do you eat fish/seafood frequently?
Describe current and significant past occupations:
Briefly describe the quality of your personal relationships:
Are you married?
How many children do you have?
In a committed relationship?
Using contraception now?
                What type?
Describe your general energy level:
Are you energetic in the morning?
Rate your current energy level with 10 being highest:
Rate the quality of your sleep with 10 being the highest:
Describe how well you sleep:
Sleep soundly?
Trouble falling asleep?
Do you snore?
Trouble staying asleep?
Describe your general sense of mood and well-being:
Happy in general?
Depressed?
Anxious?
Occasionally depressed?
Have you had any stress in your life? Please describe:
Describe your diet in general terms:
What percentage of your diet is organic?
Describe your digestion and bowel movements:
Daily?
Number of times per week?
Formed?
Voluminous?
Soft?
Hard?
Constipated?
Diarrhea?
Have you traveled outside of the United States?
Where?
Did you have a diarrhea illness associated with that travel?
Do you exercise regularly?
Please describe:

Female

First Name
Last Name
Age
Date
Your age at the time of your last menstrual period:
Your age at the time your menstrual periods were last regular:
Age of onset of menstruation (menarche):
How many years after menarche did your periods become regular?
How many days did your menstrual flow last at that time?
During your early adulthood, what was the most common length of your cycle?
(number of days from first day of menstrual flow of one cycle to the first day of flow of the next)
Prior to the age of 18 (or your first pregnancy), did you have:
PMS?
Difficult periods?
Bloating?
Headaches?
Uterine cramps?
Irritability?
Heavy flow?
Breast tenderness?
Birth Control Methods:
Diaphragm:
Condom:
Both:
IUD (number of years):
Tubal ligation:
Were you ever on the birth control pill?
Number of years:
If yes, how did you feel on it?
Did you gain weight while on it?
Number of miscarriages:
Number of abortions:
Pregnancy and Childbirth:
Total number of times you have been pregnant:
Number of live births:
Your age at each pregnancy:
Number of months you breastfed each baby:
Were the last six months of your pregnancy...
A very physically pleasant time for you?
A time you did not feel as well as when you were not pregnant?
After the first 3 months of pregnancy...
Did you have diabetes?
Did you have nausea?
        For how long?
After the age of 35...
PMS
Breast tenderness
At what time in your cycle did you feel best?
Is this the only time of the month you feel well-being?
Is there a time when your periods changed from regular to irregular?
If yes, what age?
Breast size when young or prior to first pregnancy: Bra size
Current breast size: Bra size
Have you had any of the following?
Breast cysts:
Breast biopsy:
Breast cancer:
Have you had breast mammograms?
If so, how many?
Any abnormal mammograms? (comment)
Have you had breast ultrasounds?
If so, how many?
Any abnormal ultrasounds? (comment)
Have you had breast thermograms?
If so, how many?
Any abnormal thermograms? (comment)
Do you have breast implants?
If so, at what age implanted?
Which type?
What percentage of time in a 24-hour day do you wear a bra?
Do you wear underwire bras?
Compression bras?
Have you had any of the following?
Uterine fibroids:
D and C (number of):
Ovarian cysts:
Endometriosis:
Laparoscopic surgeries:
Cesarian sections:
Tubal ligation:
Endometrial biopsy:
Hysterectomy (at what age):
Oopherectomy (removal of ovary or ovaries):
Age of last pap smear:
Abnormal pap smear (at what age):
Number of bone density tests:
Year of last bone density test:
Osteopenia?
Osteoporosis?
Normal?
Hormonal Use:
Premarin (number of years):
Prempro (number of years):
Patch (number of years):
Other hormones (list):
Has any member of your family had female cancer?
If yes, what type?
Breast Cancer:
Uterine Cancer:
Ovarian Cancer:
Who had what?
Current height:
   Feet:
Inches:
Tallest height in your lifetime:
   Feet:
Inches:
Weight at age 25:
   lbs:
Current weight:
In your lifetime, have you had more muscle and hair than others?
Describe your current libido and orgasms:
Symptoms scale for the questions that follow:
0 = Never or almost never have the symptom
3 = Occasionally have it (effect is moderate or severe)
1 = Had it in the past (do not have it currently)
4 = Frequently have it (effect is not severe)
2 = Occasionally have it (effect is not severe)
5 = Frequently have it (effect is severe)

Symptoms of Estrogen Deficiency:

Hot flashes:
Depression:
Warm rushes:
Weight gain:
Night sweats:
Awaken in middle of night:
Back and joint pain:
Kicking covers off at night:
Vaginal dryness:
Heart palpitations:
Mental fogginess:
Chest pain:
Racing mind at night:
Headaches and Migraines:
Intestinal bloating:
Diminished sexuality and sensuality:
Hair loss:
Pain on intercourse:

Symptoms of Estrogen Excess:

Breast tenderness:
Water retention:
Nipple tenderness:
Swelling:
Breast fullness:
Impatient and snappy with clear mind:
Nausea:
Breast swelling or enlargement:
Pelvic cramps:

Symptoms of Progesterone Deficiency:

Difficulty sleeping:
Anxiety and Nervousness:
Irregular period:
Spotting before period:
Water retention:
Infrequent period:
No period:
Frequent and heavy periods:
Painful breasts:
Fibrocystic breasts:
Fibroids:
Endometriosis:
Diminished sex drive:
PMS:

Symptoms of Testosterone Deficiency:

Diminished sex drive:
Diminished sense of security:
Indecisiveness:
Diminished aggressiveness:
Muscle weakness:
Diminished energy and stamina:
Muscle flabbiness:
Difficulty standing up from a squat:
Urine loss on cough:
Diminished coordination and balance:
Hair loss:
Diminished armpit, pubic, and/or body hair:
Diminished love of your body image:


General

General Health Symptoms

Symptoms scale for the questions that follow:
0 = Never or almost never have the symptom
3 = Occasionally have it (effect is moderate or severe)
1 = Had it in the past (do not have it currently)
4 = Frequently have it (effect is not severe)
2 = Occasionally have it (effect is not severe)
5 = Frequently have it (effect is severe)

Head:

Headaches:
Fainting:
Dizziness:
Convulsions:
Hair thinning:
Hair loss:
             

Eyes:

Blurred vision:
Eye pain:
Difficulty in vision:
Double vision:
Itchy eyes:
Diminished close-up vision:
Spots in front of eyes:
Do you wear glasses?
             

Ears:

Earaches:
Ear infections:
Ringing in ears:
Hearing loss:
Itchy ears:
Change in hearing:
             

Nose:

Stuffy nose:
Nasal discharge:
Nosebleeds:
Sinus problems:
Sinus infections:
Post nasal drip:
             

Allergy:

Pollen allergy:
Hay fever:
Dust allergy:
Asthma:
Frequent sneezing:
Seasonal sneezing:
Stuffy nose after eating:
Trouble going into shopping malls:
Hypersensitivity to medications:
             

Mouth and Throat:

Canker sores:
Tooth pain:
Sore gums:
Tooth sensitivity:
Bleeding gums:
Coated tongue:
Difficulty swallowing:
Breath odor:
Sore throat:
Do you floss?
             

Sleep:

Difficulty in sleeping:
Awaken in night:
Difficulty falling asleep:
Difficulty falling back asleep:
Sleep less than 7 hours:
Five hours or less of sleep per night:
Work night or afternoon shift:
Heavy snoring or gasping:
Disturbing dreams:
             

Immune:

Cold sores in the mouth:
Colds or other infections:
Known allergies:
Swollen glands:
Difficulty healing:
             

Cardiovascular:

Skipped heartbeat:
Leg cramping on walking:
Rapid or pounding heartbeat:
Leg cramps at night:
Palpitations:
High blood pressure:
Chest pain:
Pain in legs when walking:
Irregular heart beat:
Fluid retention (swelling):
Anemia:
Dizzy upon standing:
Varicose veins:
Bruise easily:
             

Lungs:

Cough:
History of smoking:
Shortness of breath during the day:
Asthma:
Shortness of breath at night:
Bronchitis:
Difficulty breathing:
             

Intestine:

Nausea:
Discomfort in abdomen:
Vomiting:
Foods you have trouble with:
Bloated feeling:
Fatigue or anxiety relieved by sweets:
Burning in stomach:
Indigestion 1-2 hours after eating:
Heartburn:
Fullness long after meals:
Pain in abdomen:
Sleepy after meals:
Diarrhea:
Nails bend or break easily:
Constipation:
Blood in stool:
Excessive belching:
Black stool:
Excessive passing of gas:
Anal itch:
Indigestion:
Pain on defecation:
Craving sweets:
Hemorrhoids:
Hepatitis:
Goosebumps on back of arms:
Gallstones:
Difficulty with oily foods:
Nausea upon eating:
Difficulty with dairy:
Change in appetite:
Difficulty with wheat:
             

Urinary Tract:

Burning or pain on urination:
Frequency of urination:
Bladder infections:
Urgency of urination:
Kidney infections:
Fluid retention (swelling):
Up at night to urinate:
Kidney stones:
Blood in urine:
             

Skin:

Pimples or acne:
Oily skin:
Dry skin:
Hives:
Rashes:
Skin itch:
Sweating:
             

Weight:

Compulsive or binge eating:
Craving certain foods:
Sweet craving:
Weight loss:
Excessive weight:
Weight gain:
Underweight:
Inability to gain weight:
             

Energy:

Fatigue in general:
Awaken energetic, fatigue easily:
Hyperactivity:
Awaken sluggish, improve with day:
             

Hormonal:

Mid-life weight gain:
Eyes sensitive to bright light:
Cold intolerance:
Irritable when hungry:
Swelling under eyes:
Feel better after exercise:
Eye discomfort in bright light:
Feel worse after exercise:
Sleep disturbance:
Cold hands and feet:
Loss of muscle mass or strength:
Uncomfortable in cold:
Sweet craving:
Uncomfortable in heat:
Fatigue easily:
Dizzy upon standing up quickly from lying or sitting:
Fatigue or irritability relieved by eating sweets:
             

Mind and Emotions (answering these questions is optional):

Poor memory:
Fear:
Poor concentration:
Sadness or grief:
Difficulty in making decisions:
Anger:
Mood swings:
Shame:
Anxiety:
Guilt:
Nervousness:
Self-pity:
Depression:
Loneliness:
Panic attacks:
Meaninglessness:
Mid-life crisis:
Hoplessness:
Irritability or moodiness:
Emptiness:
             

Dental:

Tooth or gum pain:
Gingivitis:
Root canals:
Dental implants:
Mercury amalgam fillings:
             

Liver and Toxicity:

Hypersensitivity to odors:
Trouble when smelling perfumes:
Sleep disturbance with coffee consumption after 6pm:
Trouble with odors in shopping mall:
Known toxic exposures:
             

Other (answering these questions is optional):

Present in moment:
Happiness:
Ability to accept:
Love:
Non-attachment:
Laughter:
Fun:
Stillness:
             
You have completed the entire medical questionnaire. Click Submit.
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Summary Page

First Name Last Name  
           DOB              Date Age:  
          LFW:
             CC:
Additional Notes
Patient Wants:
Head: GI:
Eyes: GU:
Ears: Skin:
Nose: Weight:
Allergy: Energy:
Mth and Th: hormonal:
Sleep: M & E:
Immune: Dental:
CV: Liv/Tox:
Lungs: Total:
Grand Total:
     PMH:  
Hosp. Child:
Hosp. Adult:
Ops. Child:
Ops. Adult:
Acc. child:
Acc. Adult:
Toxic Exposure:
               RC   IMP   Hg  
Do you snore:
Current Height: ft.     in.
Tallest Height: ft.     in.
Wgt at 25: lbs.
Wgt now: lbs.
Now Past
coff:
etoh:
rec:
cigs:
      m:       f:
mgm: pgm:
 mgf:  pgf:
Med Aller:
Meds:
Past Meds:
Anbs:


History of Stress:
Happy: Anxiety:
Depressed: Occassionally depressed:
Married:      children:
Commited relationship:
Pelvis: Breast:
hysterex:   bx:
oopherex:   Ca:
ut fibroid:   FH BCa:
  who/what:
endometriosis:   cyst:
tubal lig:   Bra:
abel pap:   underwire:
laparoscopy:   compression:
ov cysts:   bra < 35:
  bra > 35:
implants:
lmp:    E def:
lrmp:   E xs:
age onset
irreg:
  P def:
g:   T def:
p:   bt>35:
m:   FH fem
ale Ca:
ab:
contra
ception
mammo:
BMD:
          nl: enia: osis:
Energy:
Mood:
Sleep:
Libido:
Bowels:
Pain:
Diet: %
Exercise:
Remarkable labs:
Physical Exam:
hgt: wgt: temp:
bp: p: O2 sat:
Miscellaneous Important
PMH and Risk
Diagnoses