Health Assessment for Women

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
2a) Mood Changes: Irritability
2b) Mood Changes: Anxiety
2c) Mood Changes: Nervousness
2d) Mood Changes: Depression
3a) Decreased Mental Ability: Memory Loss
3b) Decreased Mental Ability: Confusion
3c) Decreased Mental Ability: Loss of Focus
4a) Hot Flashes
4b) Night Sweats
5a) Weight Gain: Bloating
5b) Weight Gain: Excessive Belly Fat
5c) Weight Gain: Inability to Lose Weight
6a) Decreased Sex Drive
6b) Vaginal Dryness
7a) Sleep Problems: Can’t Stay Asleep
7b) Sleep Problems: Can’t Fall Asleep
8) Cold Hands & Feet/Always Cold
9) Hair loss/Breakage
10) Dry Wrinkled Skin
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?
Have you had your uterus removed?
Do you still have menstrual cycles?
What type of birth control (if any) are you using?
Do you smoke tobacco?
Are you currently receiving hormone replacement therapy?
Are you currently taking Thyroid medication?
Are you currently taking Statins?
Do you have a history of breast cancer?
Do you have a history of seizures or epilepsy?
Do you have or have you had endometriosis?
Do you have fibrocystic breast disease?
Do you have a history of uterine fibroids or polyps?
Do you have PCOS?
Do you have Hashimoto's thyroiditis?
Current Weight (lbs)
Have you experienced any of the following in the past?
Acne
Breast Tenderness
Facial Hair
Pre-Menstrual Migraines
Hot Flashes
Should be Empty:

Health Assessment for Women

Symptoms

Family History

Focused Personal History

Have you experienced any of the following in the past?