• Miami Holistic Center

    FEMALE HEALTH HISTORY QUESTIONNAIRE

    To be completed before your initial consultation
     

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    For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).  

    It should take you some time to complete this form properly so ensure you have at least one hour to dedicate to this important information gathering phase.  When you are finished please click on the "Submit" button at the bottom of the form.

     

    PATIENT INFORMATION

    Your Full Name:

    Age:
    Date of Birth:
    Weight:
    Height:
    Marital Status: single married divorced widowed
    Occupation:
    Email:
    Cell Phone:
    Home Address:
    City, State, Zip:
    Employed By:
    Employer's Address:
    Emergency Contact phone & Relationship:

    How did you hear about us:  

    If referred by a friend, who may we thank?

     
    MEDICAL HISTORY

    What is the reason for this visit?

    List medications you are currently taking:

    Any known Drug Allergies?

    List natural supplements, herbs, remedies, including athletic performance supplements you are currently taking:

    List your history of GYN procedures or surgeries (ovaries, hysterectomy, tubal ligation, breast, etc.)

    Date of last pelvic/gynecological exam:

    Last Pap Test?       Last thermography?   Unusual results?

      

    List significant non-GYN health issues (diabetes, surgeries, etc.):

     

    Last mammogram?


    SIGNIFICANT ILLNESSES (PLEASE CHECK ALL THAT APPLY)

    Arthritis:
    Asthma:
    Autoimmune    :
         AIDS:
         Cancer
    Diabetes:
    Gallstones:
    Heart Disease:

    Kidney stones:
    Rheumatic fever:
    Ruptured Appendix:
         Seizures:
         Thyroid Disease:
    Venereal Disease:
    Hepatitis:
    Hypertension:
    Connective tissue disorders

     

     

     

     

     

     

    LIFESTYLE INDICATORS:  < = less than      > = greater than

    Do you use any of the following?    

    Alcohol   None      <2 drinks/day    >2 drinks/day    stopped recently, when?     

    Coffee     None    <2 cups/day  >2 cups/day        stopped recently,     when?     

    Soda       None    <2 cans/day    >2 cans/day      stopped recently,     when?          

    Sweets/refined carbs  None  less than twice/day   more than twice/day    stopped recently

    Do you smoke cigarettes/cigars or use nicotine gum or other stimulants? Yes      No

    Amount

    How would you rate your stress level? (1 =Low, 10=Extreme)        

    How would you rate your stress handling? (1=Poor, 10=Excellent)                             

    How often do you exercise? never     rarely     sometimes      regularly     competitively



     SlGNS & SYMPTOMS Ongoing With Period Mild Moderate Severe More Information
    Mood Swings
    Anxiety/Nervousness
    Overly Reactive/Short fuse
    Irritability
    Depression
    Lowered self-esteem / self-image
    Caretake others before yourself
    Sadness/Crying
    Foggy thinking
    Memory difficulties
    Fatigue
    Constant hunger
    Sweet cravings (carbs/chocolate)
    Caffeine/Stimulant cravings
    Salt cravings
    Headaches /Migraines
    Body/Joint aches/backache
    Weight gain
    Weight loss
    Water retention
    Bloating
    Irritable bowel
    Constipation
    Light colored stool
    Loose stool/Diarrhea
    Nausea/Vomiting
    Acne
    Excessive facial hair
    Body/Head hair loss
    Dry skin/Brown spots
    Lowered libido
    Heightened libido
    Hot flashes
    Night Sweats
    Breast tenderness/swelling
    Nipple discharge
    Vaginal infections
    Urinary frequency
    Incontinence
    Vaginal dryness
    Painful intercourse
    Any other symptoms not listed above?

    MENSTRUAL, CONTRACEPTIVE AND PREGNANCY HISTORY

    .Age at onset of menarche (first period):                                                           

    Are you currently using a method of birth control?  Yes       No

         If yes, what method or name of contraceptive?                

    Are you, or have you used   oral,       injected,    patch, or   ring hormone contraceptives, or used

    Emergency Contraception (aka "the morning after" pill)?   Yes      No

                    When and for how long?

        Are you using, or have you used an IUD?      Yes    No       If yes, when and for how long?

                    What type of IUD did you use?        copper         hormone            other

     

    Please describe problems that you may have experienced associated with the use of any and all birth control
    methods (such as yeast, heavy/light bleeding, mood, weight gain, acne, sweet cravings, fatigue, depression, palpitations, etc.)

        

    Have you used, or are you currently using fertility or treatment?  Yes       No

                     If yes, please explain.

     

    Have you used, or are you currently using, bioidentical hormones (such as DHEA, pregnenolone, progesterone, estrogen, testosterone, etc.)? Yes     No

         

     If yes, what hormone(s), dosage, & for how long?

     

    Have you been pregnant before? Yes       No

         Number of pregnancies:       Number of live births:         Miscarriages:    Premature births:    Cesarean births:

     Stillbirths:         Abortions:          Ectopic pregnancies:

     

     If you have had a miscarriage, how many weeks pregnant were you?

    Have you had an abnormal Pap Test?   Yes     No      Diagnosis/Findings:                

    Treatment and/or Medication:

     

     

    Have you had a vaginal infection?

    Yes

    No

    If yes, what?

     

     

    Treatment and/or Medication:

     

    Any history of Ovarian cysts?

    Yes

    No

    Uterine fibroids? Yes   No

    Fibrocystic Breasts?  

    Yes

    No

    Endometriosis?   Yes    No

    Polycystic Ovarian Syndrome (PCOS)?

    Yes

    No

     

    Cycle Information
     First day of last menstrual period (LMP)

    Have you had a tubal ligation? Yes   No     If yes, when? 

    Has there been any recent change in your cycle or symptoms associated with your cycle? Yes   No
    If yes, please provide details

     

    How many days is your current cycle?  (Counted from the first day of your period to the first day of your next period)
     < 20           20-30            30-40            40-50           >50

    How many days does menstruation typically last?

    Is your cycle regular?  Yes   No     Not always   Details: 

    Typical menstrual flow   Light    Medium    Heavy     Details:

    How many pads and/or tampons (circle) are used on heavy days?

    Do you pass clots?    Yes   No     If yes, how often?

    Do you spot?  Yes   No        

    If yes, at what point in your cycle?   

    before period    during period    after period     during ovulation

           Other

    Do you experience cramping during cycle?    None        Mild       Moderate         Severe

           Other

    If you experience cramping when?    

    before period    during period    after period     during ovulation        

    11.     Do you experience abnormal vaginal discharge? Yes   No 

    12.    Do you experience vaginal itching and/or odor?Yes   No 

    13.               Do you experience breast tenderness? None           Mild         Moderate           Severe
    At w    hat point in your cycle?  before period    during period    after period     during ovulation

    Do experience nipple discharge? None           Mild         Moderate           Severe 

    If yes, when? before period   during period   after period    during ovulation   ongoing

     

    FOR MENOPAUSAL WOMEN

     

    Your age at the onset of menopause:                           Year of onset:

    Have you had a hysterectomy?  Yes   No    If yes,  complete (ovaries AND uterus)     partial (uterus only)

    Date of hysterectomy:            Reason for hysterectomy:  

    List any other GYN related surgeries:  

     

    Describe your experience transitioning into menopause (symptoms, strong emotions, thoughts, unusual stressors, etc.)

     

     

    Have you used, or are you currently using, conventional hormone replacement therapy (HRT)?    Yes   No

                If yes, what were you prescribed?

                What dosage? For how long?

    Have you used, or are you currently using bioidentical hormone creams/gels/sublingual, troche, oral? Yes   No

                If yes,what?

                What dosage? For how long?

    Have you utilized any alternative, complementary, or natural remedies in your management of menopause?Yes   No

                If yes, what?

                For how long?

    Have you had, or do you have any vaginal spotting or bleeding since menopause? Yes   No

                If yes, when?               Were you evaluated and/or treated by a GYN? Yes   No

                Treatment

     

    PLEASE DESCRIBE YOUR CYCLE HISTORY.

    When you were menstruating, how would you have described your period?             Easy         Uncomfortable        Difficult

    What was your typical menstrual flow?    Light            Medium     Heavy

    12.    When you were cycling, would you consider your cycle regular?   Yes   No

                If no, explain.

    Please describe any 'treatment' ever received for cycle issues.



    SLEEP HABITS

    How do you sleep? Well       Trouble falling asleep      Trouble staying asleep      Insomnia

                 If experiencing sleep problems, how long has this been happening?


    Do night sweats wake you up?     Yes   No      If yes, how often?

     

    Do you wake up tired?     Yes   No

    How long has this been happening?


    Is your room completely dark when you sleep at night? (no night light, street lamp, TV, etc.) Yes   No

    Do you get at least 30 minutes of outside daylight time, several days each week?Yes   No


     

    Do you have other comments on your health?

    Please scroll up to the top and double check what you have completed and correct any error before submission.

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