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WOMEN'S CONFIDENTIAL

  MEDICAL HISTORY
 

 

EMAIL  

TODAY'S DATE   

FULL NAME
ADDRESS 1
ADDRESS 2
CITY
STATE,  ZIP STATE ZIP CODE -
HOME TELEPHONE
CELL TELEPHONE
BIRTHDATE   AGE  MM/DD/YYYY     AGE
HEIGHT,  WEIGHT  IN      WEIGHT
USE TOBACCO YESNO        PKG DAILY
USE ALCOHOL YESNO  AMT/DAY /WK
USE CAFFEINE YESNO  AMT/DAY /WK
CARBONATED BEV YESNO  AMT/DAY /WK
OCCUPATION
DOCTOR'S NAME
ADDRESS
CITY, STATE, ZIP STATEZIP
TELEPHONE
GYN DOCTOR NAME
ADDRESS
CITY, STATE, ZIP STATEZIP
TELEPHONE
FAX
ALLERGIES

MARK ALL THAT APPLY

  PENICILLINCODEINESULFA DRUGS
  MORPHINEASPIRINFOOD ALLERGIES
  DYESNITRATESNONE KNOWN
  PET ALLERGIESSEASONAL ALLERGIES
DESCRIBE REACTIONS

CHECK ALL OTC

 

PRODUCTS YOU

ACETAMINOPHENASPIRINIBUPROFEN

USE

NAPROXENCOUGH SUPPRESSANTS
  DECONGESTANTSANTIHISTAMINES
  COUGH & COLD COMBOSSLEEP AIDS
  ANTIDIARRHEALSLAXATIVES
  DIET AIDSANTACIDSACID BLOCKERS

CHECK ALL

 

SUPPLEMENTS YOU

VITAMINSMINERALSHERBALS

USE CONSISTENTLY

PROTEIN SUPPLEMENTSCALCIUM
  FISH OILSFLAXSEEDJUICE PLUS
  GLUCOSAMINEAMINO ACIDS

 

 

MEDICAL  

CONDITIONS / DISEASES
LIST ALL THAT APPLY

LIST CURRENT 

PRESCRIPTIONS

 

LIST PAST  

HORMONES
 
USED BIRTH CONTROL? YES  NO
ANY PROBLEMS? YES  NO
IF YES DESCRIBE
REGULAR EXERCISE?

TIMES PER WEEK

HOW MANY PREGNANCIES HOW MANY CHILDREN
ANY MISCARRIGES?
HAD A HYSTERECTOMY?  DATE  MM/DD/YY
OVARIES REMOVED? DATE  MM/DD/YY
TUBAL LIGATION? DATE  MM/DD/YY
   

FAMILY HISTORY 

OF ANY OF THE  FOLLOWING

UTERINE CANCER

FAMILY MEMBER

OVARIAN CANCER

FAMILY MEMBER

BREAST CANCER

FAMILY MEMBER

HEART DISEASE

FAMILY MEMBER

OSTEOPOROSIS

FAMILY MEMBER

LAST MAMOGRAM DATE OF MM/DD/YY
LAST PAP SMEAR DATE OF MM/DD/YY
DATE OF LAST PERIOD MM/DD/YY  # OF DAYS
ABNORMAL PERIODS?         EXPLAIN
 
AGE OF FIRST PERIOD
   

HOW DID YOU HEAR

  ABOUT US OR REFERRED BY?
 
   

WHAT ARE YOUR

  GOALS FOR TAKING BHRT?
 
   

PLEASE INDICATE ANY

 QUESTIONS  ABOUT BHRT
 
   

SYMPTOM

 PROFILE
   
INCREASED FORGETFULNESS
FOGGY THINKING
TEARFUL
DEPRESSED
MOOD SWINGS
FLUID RETENTION
COLD EXTREMITIES
STRESS
ANXIOUS
IRRITABLE
NERVOUS
DECREASED MENTAL SHARPNESS
MORNING FATIGUE
AFTERNOON FATIGUE
EVENING FATIGUE
DIFFICULTY FALLING ASLEEP
DIFFICULTY STAYING ASLEEP
DECREASED STAMINA
FIBROMYALGIA
RINGING IN EARS
ALLERGIES

HEADACHES/MIGRAINES

DIZZY SPELLS
SUGAR CRAVINGS
CONSTIPATION
GOITER
COLD BODY TEMPERATURE
HOARSENESS
HAIR DRY OR BRITTLE
NAILS BREAKING OR BRITTLE
SLOW PULSE RATE
RAPID HEARTBEAT
HEART PALPITATIONS
INCONTINENCE
HOT FLASHES
NIGHT SWEATS
INFERTILITY PROBLEMS
ACNE
SCALP HAIR LOSS
WEIGHT GAIN-HIPS
WEIGHT GAIN-WAIST
HIGH CHOLESTEROL
ELEVATED TRIGLYERIDES
DECREASED LIBIDO
DECREASED MUSCLE MASS
DECREASED FLEXIBILITY
BURNED OUT FEELING
SORE MUSCLES
INCREASED JOINT PAIN
NECK OR BACK PAIN
BONE LOSS
THINNING SKIN
RAPID AGING
ACHES AND PAINS
IBS
VAGINAL DRYNESS
IRREGULAR PERIODS
UTERINE FIBROIDS
WATER RETENTION
TENDER BREASTS
FIBROCYSTIC BREASTS
INCREASED FACIAL/BODY HAIR
   

 

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