Health Assessment for Women
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Symptoms
Please Specify Severity
1. Hot Flashes
Never
Mild
Moderate
Severe
Very Severe
2. Sweating (night sweats or increased episodes of sweating)
Never
Mild
Moderate
Severe
Very Severe
3. Sleep problems (difficulty falling asleep, sleeping through the night, or waking up too early)
Never
Mild
Moderate
Severe
Very Severe
4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
Never
Mild
Moderate
Severe
Very Severe
5. Irritability (mood swings, feeling aggressive, angers easily)
Never
Mild
Moderate
Severe
Very Severe
6. Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Never
Mild
Moderate
Severe
Very Severe
7. Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation).
Never
Mild
Moderate
Severe
Very Severe
8. Sexual problems (changes in sexual desire, sexual activity, orgasm and/or satisfaction)
Never
Mild
Moderate
Severe
Very Severe
9. Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
Never
Mild
Moderate
Severe
Very Severe
10. Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
Never
Mild
Moderate
Severe
Very Severe
11. Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Never
Mild
Moderate
Severe
Very Severe
12. Difficulties with memory
Never
Mild
Moderate
Severe
Very Severe
13. Problems with thinking, concentrating or reasoning
Never
Mild
Moderate
Severe
Very Severe
14. Difficulty learning new things
Never
Mild
Moderate
Severe
Very Severe
15. Trouble thinking of the right word to describe persons, places, or things when speaking
Never
Mild
Moderate
Severe
Very Severe
16. Increase in frequency or intensity of headaches or migraines
Never
Mild
Moderate
Severe
Very Severe
17. Hair loss, thinning or change in texture of hair
Never
Mild
Moderate
Severe
Very Severe
18. Feel cold all the time or have cold hands or feet
Never
Mild
Moderate
Severe
Very Severe
19. Weight gain or difficulty losing weight despite diet and exercise
Never
Mild
Moderate
Severe
Very Severe
20. Dry or wrinkled skin
Never
Mild
Moderate
Severe
Very Severe
Severity Score
Severity score: Mild:1-20 / Moderate 21-40 / Severe 41-60 / Very Severe 61-80
Family History
Family: Heart Disease
Yes
No
Family: Diabetes
Yes
No
Family: Osteoporosis
Yes
No
Family: Alzheimer’s Disease
Yes
No
Family: Breast Cancer
Yes
No
Focused Personal History
Are you currently pregnant or trying to conceive?
Yes
No
Have you had your uterus removed?
Yes
No
Do you still have menstrual cycles?
Yes
No
What type of birth control (if any) are you using?
None
Birth Control Pill (combined)
Birth Control Pill (progestin only)
Birth Control Patch (OrthoEvra)
Birth Control Implant (Nexplanon)
Abstinence
DepoProvera
IUD - Mirena
IUD - Kyleena
IUD - Skyla
IUD - Other
Menopause
NuvaRing
Tubal Ligation
Hysterectomy
Other
Do you smoke tobacco?
Yes
No
Are you currently receiving hormone replacement therapy?
Yes
No
Are you currently taking Thyroid medication?
Yes
No
Are you currently taking Statins?
Not answered.
Yes
No
Do you have a history of breast cancer?
Yes
No
Do you have a history of seizures or epilepsy?
Yes
No
Do you have or have you had endometriosis?
Yes
No
Do you have fibrocystic breast disease?
Yes
No
Do you have a history of uterine fibroids or polyps?
Yes
No
Do you have PCOS?
Yes
No
Do you have Hashimoto's thyroiditis?
Yes
No
Current Weight (lbs)
Have you experienced any of the following in the past?
Acne
Yes
No
Breast Tenderness
Yes
No
Facial Hair
Yes
No
Pre-Menstrual Migraines
Yes
No
Hot Flashes
Yes
No
Submit
Should be Empty: