Date
Name
Age
Height
Weight
Birthdate
Street Address
City
State
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Maryland
Massachusetts
Michigan
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Mississippi
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New Hampshire
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Ohio
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
Phone Number
Occupation
What is your greatest need or problem? (List the most important; then list other issues in order of importance):
Your current medical conditions or diagnoses:
Drug allergies:
Allergies to food, pollens, environment, etc:
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:
Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:
Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:
If you are you currently taking medication for a thyroid condition, which one and dose?
Have you ever had a bone density scan?
Do you use tobacco products?
Do you use alcohol products?
Do you use caffeine products?
Do you use recreational drugs?
How much water do you drink in one day (24 hr)?
Is your drinking water from a:
Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):
When was your last general medical exam:
Have you ever had an abnormal Pap?
At what age was your First Period (menarche)?
When was your most recent or last period (LMP):
Do you still have your period?
Do you have pain at any other time in your cycle?
Any current changes in your normal cycle?
Any bleeding between periods (IMB):
What were your periods like as a teenager?
Have you have ever had Premenstrual Symptoms (PMS), please describe:
How long have you had PMS symptoms?
Starting and ending when:
If your periods have ever been difficult, irregular, or abnormal in any way, please describe:
If you are you currently having any pelvic pain, pressure, or fullness, describe:
Describe any recent unusual vaginal discharge or itching:
Treatment for any of above:
Have you ever used any of the following birth control methods:
Tubes tied (tubal ligation)?
Uterus removed (hysterectomy)?
Ovaries removed (oophorectomy)?
Were there any problems associated with the surgery or removal of any of these organs?
Has your doctor diagnosed menopause, or told you that you are in menopause?
If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed?
Have you ever been pregnant?
Are you trying to get pregnant?
What was your age at your first pregnancy?
How many times have you been pregnant (gravida)?
How many pregnancies resulted in the birth of living children (para)?
Were there any problems?
Any interrupted pregnancies (miscarriages or abortions)?
Current birth control method:
How long:
Any problems?
Have you ever used any of the following birth control methods:
Oral Contraceptives (Birth Control Pills)
Total months/years used:
Describe any side effects to Birth Control Pills:
Intra-Uterine Device (IUD)
When was your last mammogram?
Results:
Do you examine your breasts monthly?
Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details:
Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions?
If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:
CHECK A BOX FOR EACH SYMPTOM
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