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*

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
How would you describe your health at the present?*
How much do you think your bladder problems affects your life?*
Category 1 | Sex Hormone Imbalance

AcneBone lossCystic ovariesDepressed moodFibrocystic breastsFoggy thinkingHeadachesHeart palpitationsHeavy mensesHot flashesIncreased body/facial hairIrritabilityLow libido/decreased sexual functionMood swings (PMS)Night sweatsUrinary incontinenceUterine fibroidsVaginal drynessWeight gain
Category 2 | Adrenal Hormone Imbalance

Aches/painsAfternoon/evening fatigueAllergiesAnxietyAutoimmune diseaseBone lossChronic health problemsDepressionDiabetes/prediabetesHistory of steroid usageLow blood sugarMorning fatigueSalt/sugar cravingsSleep disturbancesSusceptibility to infectionsWeight gain
Category 3 | Thyroid Hormone Imbalance

Aches/painsAnxietyBrittle nailsCold hands/feetConstipationDepressionDry skinElevated cholesterolFatigueFeeling coldFoggy thinkingHeadachesHeart palpitationsInability to lose weightInfertilityLow libidoMenstrual irregularitiesSleep disturbancesThinning hairWeight gain
Category 4 | Metabolic Imbalance

Diabetes (or family history)Elevated cholesterolFatigueGestational diabetes (or family history)Heart disease/stroke (or family history)High blood pressureHigh blood sugarInsulin resistanceLow physical activityLow thyroid/decreased sexual functionPCOSSalt/sugar cravingsSmoking (or history of)Thyroid disordersWeight gain
Category 5 | Neurotransmitter Imbalance

ADD?ADHDAddictive behaviorsAnxious/nervousAutism spectrum disorderDepressedDevelopmental delaysEating disordersIrritableMethylation deficitsMood swingsOCDPanic attacksPMDD (Premenstrual Dysphoric DisorderSleep disturbedTearful
Should be Empty:

Female Hormone Symptom Checklist