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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 CURENT 

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
   
HOT FLASHES
NIGHT SWEATS
VAGINAL DRYNESS
INCONTINENCE
BLEEDING CHANGES
UTERINE FIBROIDS
WATER RETENTION
TENDER BREASTS
FIBROCYSTIC BREASTS
INCR FORGETFULNESS
FOGGY THINKING
TEARFUL
DEPRESSED
MOOD SWINGS
STRESS
MORNING FATIGUE
EVENING FATIGUE
DIFFICULTY SLEEPING
DECREASED STAMINA
ANXIOUS
IRRITABLE
NERVOUS
FIBROMYALGIA
ALLERGIES
HEADACHES
SUGAR CRAVINGS
DIZZY SPELLS
COLD BODY TEMPERATURE
GOITER
HOARSENESS
HAIR DRY OR BRITTLE
NAILS BREAKING OR BRITTLE
CONSTIPATION
SLOW PULSE RATE
RAPID HEARTBEAT
HEART PALPITATIONS
INFERTILITY PROBLEMS
ACNE
INCREASE FACIAL/BODY HAIR
SCALP HAIR LOSS
WEIGHT GAIN HIPS
WEIGHT GAIN WAIST
HIGH CHOLESTEROL
ELEVATED TRIGLYCERIDES
DECREASED LIBIDO
DECR MUSCLE SIZE
THINNING SKIN
RINGING IN EARS
RAPID AGING
ACHES AND PAINS
BONE LOSS

 

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