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Microsoft word - 2b. female health history questionnaire

Female Health History Questionnaire
These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan. First Name: ______________________ Last Name: _____________________________ Today’s Date: __________ Address:___________________________________ City: _________________ State: _______ ZIP: _____________ Best Phone # to reach you: (________) ________-___________ Birth Date: _____/____/________ Age: _______ Occupation: __________________ How did you hear about me?: ______________________________ Height: _____′ ______ ″ Weight: _________ Marital Status: ____________________ Sex: __________ Email if interested newsletter _____________________________________________ Insurance Company ___________________ Are you pregnant? Yes ____ No _____ Are you breastfeeding? Yes ____ No _____
Are you cyclic? Yes ____ No _____ Are you in Menopause? Yes ____ No _____
Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptoms has been present. Problem Onset

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List any health issues of parents and siblings __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ YOUR MEDICAL HISTORY
List Any Surgeries/Hospitalizations: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IMMUNIZATION HISTORY
Have you received any vaccinations in the last 5 years? Yes____ No____ If yes, please list. ____________________________________________________________________________________ ____________________________________________________________________________________ DENTAL HISTORY
Do you currently have any amalgam, silver, metal, and/or gold fillings? Yes____ No____ If yes, how many? ________If yes, please list which kinds. ____________________________________________ How long have you had these fillings? ___________________________________________________ If you do not have any fillings in your mouth, have you had any fillings removed in the last 12 months? Yes____ No____ Have you had any dental work done in the last 12 months? Yes____ No____ MEDICATIONS & SUPPLEMENTS
Medications: Please list any medications that you are Supplements: List all vitamins, minerals and other currently taking or have taken in the last month, including nutritional supplements that you are currently taking. antibiotics, non-prescription drugs, and prescription drugs. Medication Name
Supplement Name/Brand
Have your medications or supplements ever caused you unusual side effects or problems? Yes ____ No _____ If yes, please describe:_______________________________________________ Any oral steroids (ie, Cortisone)? ______ If so, when? _________________ How long? ___________ Any antibiotics? ________ If so, when? __________________ How long? _______________________ Were you breast fed or bottle fed? __________________ If breast fed, how long? _________________ SLEEP/REST
 >10  8 – 10  6 – 8  <6 Do you have trouble falling asleep? Yes ____ No _____ Do you feel rested upon awakening? Yes ____ No _____ Do you have problems with staying asleep? Yes ____ No _____ If so, when? ______________ Do you snore? Yes ____ No _____ Do you use sleeping aids? Yes ____ No _____Explain:__________________________________

Currently using tobacco? Yes ____ No _____ How many years? ______ Packs per day: __________
If yes, what type? Cigarette _____ Smokeless _____ Cigar _____ Pipe _____ Patch/Gum _________
Previous smoking: How many years? _____ Packs per day: _______
Are you exposed to 2nd hand smoke? If yes, please explain: ___________________________________
How many drinks currently per week? 1 drink = 5 ounces wine, 12 oz. beer, 1.5 ounces spirits None _____ 1-3 _____ 4-6 _____ 7-10 _____ >10 _____ Previous alcohol intake? Yes ____ (Mild _____ Moderate _____ High _____) EXERCISE
Do you exercise? ______ If so, what type? _____________________ How long is the session? ________ How many CAFFEINE INTAKE
How many cups of coffee per day? None _____ 1-3 _____ 4-6 _____ 7-10 _____ Do you add anything to your coffee? Yes No If so, what do you add to it? ___________________________ How many cans of soda per day? None _____ 1-3 _____ 4-6 _____ 7-10 _____ Is the soda you drink, diet soda? Yes ______ No _______ How much water do you drink? ______cups a day PREGNANCY HISTORY Check box if yes and provide number of)
_______________  Vaginal deliveries _________ _________________  Living Children ___________  Breast feeding For how long?______________________________ FOR THE CYCLIC AGE WOMAN

Age at 1st period:_____ Menses Frequency: ______
Clotting: Yes _____ No _____ Has your period skipped? ______________ For how long? ________________ Last Menstrual Period: ________ Do you currently use contraception? Yes _____ No _____ If yes, what type do you use? Have you ever used hormonal contraception? Yes ____ No ____ If yes, when ____________________________  Birth control pills  Patch/Injection Are you using the pill now? Yes ______ No ________ Did taking the pill agree with you? Yes ______ No ________ In the 2nd half of your cycle, do you have symptoms of breast tenderness, water Breast Biopsy/Date ___________________________ Last PAP Test: _____________ Normal ________ Abnormal _______ Other information for us to know: _________________________________________________________________ FOR THE WOMAN IN MENOPAUSE

Age at onset of menopause: __________________
Year of onset of menopause: __________________ When you were cycling, would you consider your cycle regular? Yes _____ No _____ If no, why? __________________________________________________________________________________ When you were cycling, what was your typical menstrual flow? Light _____ Medium _____ Heavy _____ Have you had a hysterectomy? Complete (ovaries and uterus) _________ Partial (uterus only) ___________ Date of hysterectomy _________________ Reason for hysterectomy: __________________________________ Date of last Mammogram ______________________ Breast Biopsy/Date _______________________________ Date of last Bone Density ______________________ Results:  High  Low  Within normal range Are you in menopause? Yes _______ No _______ Age at Menopause _______________  Other ______________________________________________________ How long have you been on hormone replacement? __________________________________________________
Other information for us to know: _________________________________________________________________

Other Information

On a scale of 1-10, how would you rate your energy level? _______ On a scale of 1-10, how would you rate your stress level? _______ What would you attribute your stress level to? Ex: finances, work, home _______________________________________________________________________________________ How many times a day do you eat including snacks? __________ Do you use any sugar substitutes such as splenda, equal, crystal light, etc? _________ If so, how many packets? ______ How are your bowel movements? Please fill in the chart below with information about your bowel movements: Thank you for your time filling this out. Please send back in stamped envelope and bring any recent lab work and current supplements with you as well.


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