Women's Health Survey

Women's Health Survey
Do you RESIDE in the following states: MI, FL, IL, MN, OH, or WI?
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Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Information - Page 1 of 9
Today's Date

MonthDayYear
Date
Personal Information
Name

First NameLast Name
Weight
Height
Age
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home or Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Occupation

Health Information - Page 2 of 9
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 the 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 Qual, Black Cohosh, Gensing, Melatonin, etc. or other):
List ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:

Health Information Continued - Page 4 of 9
Number of ounces or glasses of water you drink in one day (24 hours)
Measured in:
Where is your drinking water from?
Dietary restrictions (such as salt, carbohydrates, milk products, red meat, etc):
When was your latest general medical exam?

MonthDayYear
Date
When was your last pelvic exam?

MonthDayYear
Date
Have you ever had an abnormal pap?
What was the abnormal pap result?
What if any treatment for 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?
If yes, how many days from the start of one period to the start of the next?
Number of days of flow:
Amount of bleeding:
Describe any cramping or pain you may have:

Health Information Continued - Page 6 of 9
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 had any of the following surgeries?
Tubes tied (tubal ligation)?
When?
At what age?
Uterus removed (hysterectomy)?
When?
Why?
Ovaries removed (oophorectomy)?
If Yes or PART, What?
When?
Why?
Were there any problems associated with the surgery or removal of any of these organs?

Health Information Continued - Page 8 of 9
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)
Problems?
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:

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Hot flushes
Night sweats
Light-headed feelings/dizziness
Headaches
Sleep disorders/Sleeplessness
Unusual tiredness/Fatigue
Irritability
Depression
Anxiety/Tension/Nervousness
Mood swings/Mood changes
Confusion/Difficulty concentrating
Forgetfulness/Short-term memory loss
Angry outbursts/Arguments/ Violent tendencies
Crying easily
Backache
Joint pains
Muscle pains
Muscle cramps/spasms
Problems with wound healing time
Acne/Pimples/Skin flushing
New facial hair
Dry skin/Dry hair
Crawling feeling under skin
Frequent Urinary Tract Infection (UTI)
Urinary frequency
Vaginal dryness
Abnormal bleeding
Pelvic pain, pressure, fullness, or bloating
Uncomfortable intercourse
Loss of sexual feeling/desire
Loss of arousability & capacity for orgasm
Loss of vitality
Nipple sensitivity
Discharge or leaking from nipples
Breast tenderness
Loss of pubic hair
Swelling of hands, ankles, or breasts
Heart palpitations
Shortness of breath
Food /sweets /salt cravings
Increased appetite/weight gain
Visual disturbance or decreased vision
Difficulty hearing
Diminished sense of taste
Diminished sense of smell