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) Fatigue
Never
Mild
Moderate
Severe
2) Mood Changes: Irritability/Anxiety/Nervousness/Depression
Never
Mild
Moderate
Severe
3) Decreased Mental Ability: Memory Loss, Confusion, Loss of Focus
Never
Mild
Moderate
Severe
4) Hot Flashes/Night Sweats
Never
Mild
Moderate
Severe
5) Weight Gain: Bloating, Excessive Belly Fat, Inability to Lose Weight
Never
Mild
Moderate
Severe
6) Decreased Sex Drive: Vaginal Dryness
Never
Mild
Moderate
Severe
7) Sleep Problems: Can’t Stay Asleep, Can’t Fall Asleep
Never
Mild
Moderate
Severe
8) Cold Hands & Feet/Always Cold
Never
Mild
Moderate
Severe
9) Hair loss / Breakage
Never
Mild
Moderate
Severe
10) Dry Wrinkled Skin
Never
Mild
Moderate
Severe
Family History
Heart Disease
Yes
No
Diabetes
Yes
No
Osteoporosis
Yes
No
Alzheimer’s Disease
Yes
No
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?
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
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