Female Consultation Form

HOWARD HEALTH AND WELLNESS

COREY HOWARD, MD, FACP, FMNM, ABAARM
Board Certified, Internal Medicine

1048 Goodlette Road, Suite 101, Naples, FL 34102

O:239 331-2285 F: 239 331-2347
All of your information will remain confidential between you and Dr. Corey Howard.

Please take your time filling out this questionnaire completely and honestly.
PATIENT DETAILS
Full Name

First NameLast Name
Birth Date:

MonthDayYear
E-mail*
SYMPTOMS OF MENOPAUSE
Check if you have ever had the following:

Hot flashesNight sweatsVaginal drynessAnxietyMood swingsIrritabilityInsomniaDepressionLoss of sexual interestHair growth on the facePainful intercoursePanic attacksWeird dreamsUrinary tract problemsVaginal itchingLower back painBloatingFlatulenceIndigestionOsteoporosisAching jointsHair lossFrequent urinationSnortingSore breastsPalpitationsVaricose veinsUrinary leakageDizzy spellsSkin feeling crawlyMigraine headachesMemory lapsesWeight gainOther
Additional information related to Menopausal symptoms you would like us to know:
ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPAA PRIVACY ACT

THIS FORM IS CONFIDENTIAL AND HIPAA APPROVED
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HOWARD HEALTH AND WELLNESS