Health Assessment for Women

Health Assessment for Women
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number

Area CodePhone Number
Symptoms

Please Specify Severity
1. Hot Flashes (burst that starts in chest and lasts for short duration)
2. Sweating (night sweats or increased episodes of sweating)
3. Sleep problems (difficulty falling asleep, sleeping through the night, or waking up too early)
4. Depressive mood (feeling down, sad, on the verge of tears, decline in drive or interest, loss of "zest for life")
5. Irritability (mood swings, feeling aggressive, angers easily)
6. Anxiety (feeling overwhelmed, inner restlessness, feeling panicky, feeling nervous, inner tension)
7. Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation).
8. Sexual problems (changes in sexual desire, sexual activity, orgasm and/or satisfaction)
9. Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
10. Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
11. Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
12. Difficulties with memory (concentration, finding the right word, or retaining information)
13. Problems with thinking, concentrating or reasoning
14. Difficulty learning new things
15. Trouble thinking of the right word to describe persons, places, or things when speaking
16. Increase in frequency or intensity of headaches or migraines
17. Hair loss, thinning or change in texture of hair
18. Feel cold all the time or have cold hands or feet
19. Weight gain or difficulty losing weight despite diet and exercise
20. Dry or wrinkled skin
Severity Score
Severity score: Mild:1-20 / Moderate 21-40 / Severe 41-60 / Very Severe 61-80
Family History
Family: Heart Disease
Family: Diabetes
Family: Osteoporosis
Family: Alzheimer’s Disease
Family: Breast Cancer
Focused Personal History
Are you currently pregnant or trying to conceive?
Had a recent mammogram (within last 12 months)?
Have you had your uterus removed?
If yes, which type of hysterectomy?
Do you still have menstrual cycles? (within last 12 months)
What type of birth control (if any) are you using?
Do you smoke tobacco?
Are you currently receiving hormone replacement therapy?
If yes, select types of hormones:
List name and dose of hormone(s):
Are you currently taking Thyroid medication?
Are you currently on oral nitrates?
Are you currently taking Statins?
Do you have a history of breast cancer?
Do you have a history of seizures or epilepsy?
Do you have or have you had endometriosis?
Had an endometrial ablation?
Do you have fibrocystic breast disease?
Do you have a history of uterine fibroids or polyps?
Do you have PCOS?
Do you have Hashimoto's thyroiditis?
Current Weight (lbs)
Have you experienced any of the following in the past?
Acne
Breast Tenderness
Facial Hair
Pre-Menstrual Migraines
Hot Flashes
Should be Empty:

Health Assessment for Women

Symptoms

Family History

Focused Personal History

Have you experienced any of the following in the past?