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Microsoft word - 2b. female health history questionnaire

Female Health History Questionnaire
GENERAL INFORMATION
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 _____
COMPLAINTS/CONCERNS
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
Frequency
Severity

ALLERGIES
Medication/Supplement/Food
Reaction
_________________________________________ ___________________________________________________
_________________________________________ ___________________________________________________
_________________________________________ ___________________________________________________
_________________________________________ ___________________________________________________

FAMILY HEALTH HISTORY
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:__________________________________

LIFESTYLE INDICATORS
TOBACCO HISTORY
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: ___________________________________
ALCOHOL INTAKE
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.

Source: http://www.nourishingwayscenter.com/images/female-health-questionnaire.pdf

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