Patient Medical History Form

SouthPointe Plaza

1901 E 32nd St Ste 20

Joplin MO

(417) 781-2046

www.apclinic.net
Female Hormone Symptom Checklist
Date *

Month Day Year
Date
Patient Name *

First Name Middle Name Last Name
Patient Birth Date *

Month Day Year
Patient Gender *
Category 1 | Sex Hormone Imbalance

Acne Bone loss Cystic ovaries Depressed mood Fibrocystic breasts Foggy thinking Headaches Heart palpitations Heavy menses Hot flashes Increased body/facial hair Irritability Low libido/decreased sexual function Mood swings (PMS) Night sweats Urinary incontinence Uterine fibroids Vaginal dryness Weight gain
Category 2 | Adrenal Hormone Imbalance

Aches/pains Afternoon/evening fatigue Allergies Anxiety Autoimmune disease Bone loss Chronic health problems Depression Diabetes/prediabetes History of steroid usage Low blood sugar Morning fatigue Salt/sugar cravings Sleep disturbances Susceptibility to infections Weight gain
Category 3 | Thyroid Hormone Imbalance

Aches/pains Anxiety Brittle nails Cold hands/feet Constipation Depression Dry skin Elevated cholesterol Fatigue Feeling cold Foggy thinking Headaches Heart palpitations Inability to lose weight Infertility Low libido Menstrual irregularities Sleep disturbances Thinning hair Weight gain
Category 4 | Metabolic Imbalance

Diabetes (or family history) Elevated cholesterol Fatigue Gestational diabetes (or family history) Heart disease/stroke (or family history) High blood pressure High blood sugar Insulin resistance Low physical activity Low thyroid/decreased sexual function PCOS Salt/sugar cravings Smoking (or history of) Thyroid disorders Weight gain
Category 5 | Neurotransmitter Imbalance

ADD?ADHD Addictive behaviors Anxious/nervous Autism spectrum disorder Depressed Developmental delays Eating disorders Irritable Methylation deficits Mood swings OCD Panic attacks PMDD (Premenstrual Dysphoric Disorder Sleep disturbed Tearful
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Female Hormone Symptom Checklist