Women's Health History Form

Women's Health History Form
Name

First Name Last Name
Today's Date

Month Day Year
Date
Please write in your top 3 health complaints/ concerns inorder of importance to you. Check the items that make it better or worse and mark the severity of the condition on the scale from 1-5 (0=No symptoms, 5=worst ever)
Complaint #1

Intensity Level (1=Low Intensity Level; 5=High Intensity Level)

	1	2	3	4	5

1 is Low, 5 is High

Intensity Level (1=Low Intensity Level; 5=High Intensity Level)

	1	2	3	4	5

1 is Low, 5 is High

Intensity Level (1=Low Intensity Level; 5=High Intensity Level)

	1	2	3	4	5

1 is Low, 5 is High

Heat Makes It

Better No Change Worse
Cold Makes It

Better No Change Worse
Damp Weather Makes It

Better No Change Worse
Exercise Makes It

Better No Change Worse
Medical History: Please check any that apply to you

Cancer Diabetes Hepatitis Heart Disease High Blood Pressure Stroke Seizure Thyroid Asthma Pacemaker Osteoporosis Herpes Autoimmune Disease
AIDS/HIV STD Rheumatic Fever Alcoholism Mental Illness Addiction Kidney Disease Anemia Glaucoma Tuberculosis
List Allergies:
List Current Medications/Supplements
List injuries and surgeries, date, and affected body area
Do you follow a special diet? (Vegetarian, Vegan, Raw, Paleo, Low Carb, etc.)

Lifestyle and Habits

Sleep

Difficulty falling asleep Difficulty staying asleep Wakes to urinate more than once Disturbing dreams Restless sleep Unrested upon waking
Sleep # of hours per night
Emotions

Anger Irritability Anxiety Worry Obsessive thinking Sadness/Grief
Depression Mood swings Joy Fear Timid/Shy Indecision
Eyes-Ears-Nose-Throat

Poor vision Red eyes Itchy eyes Floaters Eye pain Poor hearing Ringing in ears Earache
Sinus congestion Phlegm Sore throat Cough Mouth sores Bleeding gums Tooth grinding
TEMPERATURE

How warm/cold do you feel (not in degrees); relative to other people do you wear more or less clothing, etc.
Check all that apply

Cold Hands Cold Feet Chills Cold to the bones Areas of numbness
Night sweats Unusual sweats Hot hands, feet, chest Hot flashes Hot in afternoon Hot at night
Thirst but no desire to drink Absence of thirst Always thirsty Desires cold or iced drinks Desires hot or warm drinks

Body Temperature: 1=Cold; 3=Normal; 5=Hot

	1	2	3	4	5

1 is Cold, 5 is Hot

MOISTURE

Your overall body moisture (hair, skin, mouth, etc.)
Check all that apply

Dry skin Dry hair Dry eyes Dry brittle nails Dry mouth Dry lips Dry throat Dry nose Nosebleeds
Rashes/hives Itching Edema/Swelling Oily skin Oily hair Pimples Weight gain/loss

Moisture Level (1=Dry; 3=Normal; 5=Oily)

	1	2	3	4	5

1 is Dry, 5 is Oily

DIGESTION
How many BM's per day
Are your stools well formed?

Yes No
Check all that apply

Alternating diarrhea/constipation IBS Fatigue after BM Belching Poor appetite Nausea Vomiting Bad breath
Excessive hunger Indigestion Heartburn Acid reflux Dry stool Hemorrhoids Foul smelling stool Feels incomplete

Indicate your overall digestion (1=Diarrhea; 3=Normal; 5=Constipation)

	1	2	3	4	5

1 is Diarrhea, 5 is Constipation

ENERGY
Check all that apply

Energy drop after eating Fatigue Shortness of breath Heart palpitations Depends on caffeine/stimulants Wired/ungrounded feeling Body/limbs feel heavy
Body/limbs feel weak Bleeds easily Bruises easily Hard to concentrate Poor memory Dizziness/lightheaded High blood pressure Low blood pressure
List what time of day you have drop in energy
If you have headaches, list how often

Energy level (1=Low; 3=Normal; 5=High)

	1	2	3	4	5

1 is Low Energy, 5 is High Energy

URINARY
Number of times per day that you urinate
Check all that apply

Frequent urination Painful urination Burning sensation Urgency to urinate Cloudy urine Blood in urine
Dribbling Difficulty starting/stopping Incontinence Incomplete sensation Kidney stones
MENSTRUATION
Age at first period
Date of last period
Duration of period (e.g. 5 days; 7 days)
Length of cycle (e.g. 30 days; 27 days)
Number of pregnancies
Number of births
Are you sexually active?

Yes No
Are you pregnant?

Yes No
List type of birth control you are using
Check all that apply

Heavy periods Light periods Painful periods Irregular cycle PMS Cramps Clots Mid-cycle spotting
Fatigue with menses Fibroids Ovarian cysts Endometriosis Herpes Gonorrhea Syphilis Yeast infections Hysterectomy IVF or other fertility treatment
MENOPAUSE
If you currently have hot flashes, list frequency (e.g. 7 times per day)
If you currently have night sweats, list how many times per week
Check all menopausal symptoms that apply

Vaginal dryness Insomnia Loss of sex drive Mood disturbance
If you would like us to review any test results, you can upload them here

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We greatly appreciate your time in filling out your healt history. . .it is the first step in enabling us to give you the most appropriate and high quality care that you expect from our clinic.
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