What is your greatest need or problem? (List the most important; then list other issues in order of importance):
Invalid Input
Your current medical conditions or diagnoses:
Invalid Input
Drug allergies:
Invalid Input
Allergies to food, pollens, environment, etc:
Invalid Input
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:
Invalid Input
Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:
Invalid Input
Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:
Invalid Input
If you are you currently taking medication for a thyroid condition, which one and dose?
Invalid Input
Have you ever had a bone density scan?
Invalid Input
When and what's the result?
Invalid Input
Do you use tobacco products?
Invalid Input
For how long?
Invalid Input
Do you use alcohol products?
Invalid Input
How Much and How Long?
Invalid Input
Do you use caffeine products?
Invalid Input
What and How Much ?
Invalid Input
Do you use recreational drugs?
Invalid Input
What Recreational Drug and How Much?
Invalid Input
How much water do you drink in one day (24 hr)?
Invalid Input
Is your drinking water from a:
Invalid Input
Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):
Invalid Input
When was your last general medical exam:
Invalid Input
When was your last pelvic exam:
Invalid Input
Have you ever had an abnormal Pap?
Invalid Input
When and What Treatment
Invalid Input
At what age was your First Period (menarche)?
Invalid Input
When was your most recent or last period (LMP):
Invalid Input
Do you still have your period?
Invalid Input
If Yes, how many days from the start of one period to the start of the next?
Invalid Input
Number of days of flow:
Invalid Input
Amount of bleeding:
Invalid Input
Describe any cramping or pain you may have:
Invalid Input
Do you have pain at any other time in your cycle?
Invalid Input
Where, when, how long?
Invalid Input
Any current changes in your normal cycle?
Invalid Input
Any bleeding between periods (IMB):
Invalid Input
When and describe:
Invalid Input
What were your periods like as a teenager?
Invalid Input
Have you have ever had Premenstrual Symptoms (PMS), please describe:
Invalid Input
How long have you had PMS symptoms?
Invalid Input
Starting and ending when:
Invalid Input
If your periods have ever been difficult, irregular, or abnormal in any way, please describe:
Invalid Input
If you are you currently having any pelvic pain, pressure, or fullness, describe:
Invalid Input
Describe any recent unusual vaginal discharge or itching:
Invalid Input
Treatment for any of above:
Invalid Input
