Judith Crabtree, WH-NP
Today's Date:
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Month
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Day
Year
Date
Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Occupation
Marital Status
Race/Ethnicity:
Sexual Orientation:
Heterosexual
Homosexual
Bisexual
Name of Primary Care Provider:
Referred By:
Reason for today's visit:
General Medical History
1) Have you had a Pap smear?
Yes
No
Date
-
Month
-
Day
Year
Date
Result
Normal
Abnormal
2) Have you had a Mammogram?
Yes
No
Date
-
Month
-
Day
Year
Date
Result
Normal
Abnormal
3) Have you had a colonoscopy?
Yes
No
Date
-
Month
-
Day
Year
Date
Result
Normal
Abnormal
4) Have you had a Bone Density?
Yes
No
Date
-
Month
-
Day
Year
Date
Result
Normal
Abnormal
5) New Allergies:
None
List Allergies:
6) New Surgeries:
None
List Surgeries:
7) New Medical Problems:
None
List:
8) Current Medications and Supplements List Dose:
None
See Attached
List Medications:
9) Current Complementary or Alternative Therapy
None
List:
10) Weekly Exercise Routine
None
List:
11) Do you currently smoke Cigarettes?
Yes
No
# Years:
Use Recreational Drug Use?
Yes
No
Alcohol Use?
Yes
No
Drinks per week:
Caffeinated Beverages:
Yes
No
Cups per day:
12) Do you snore?
Yes
No
13) Have you ever been told you hold your breath during sleep?
Yes
No
14) Preferred Pharmacy:
15) Do you vape nicotine or other substances?
Yes
No
Back
Next
HORMONE SYMPTOM INVENTORY
Name
DOB
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
WHAT FORM OF CONTRACEPTION OR HORMONE THERAPY DO YOU CURRENTLY USE ?
HOW LONG?
HAVE YOU HAD A HYSTERECTOMY?
Yes
No
Year
OVARIES REMOVED?
Yes
No
Year
HAVE YOU RECENTLY EXPERIENCED?
A LOSS IN HEIGHT
UNEXPLAINED WEIGHT GAIN
UNEXPLAINED WEIGHT LOSS
A LOSS IN HEIGHT: NML HEIGHT?
UNEXPLAINED WEIGHT GAIN: NML WEIGHT?
UNEXPLAINED WEIGHT LOSS: NML WEIGHT?
FOR THE FOLLOWING PLEASE SELECT THE NUMBER THAT BEST DESCRIBES YOUR CURRENT DEGREE OF SYMPTOMS
APPEARANCE
1) ONSET/WORSENING OF ACNE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) EXCESSIVE & UNWANTED HAIR GROWTH
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) ONSET/WORSENING OF HAIR LOSS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) DRY SKIN
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) RECENT ONSET OF DENTAL PROBLEMS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
BALANCE
1) DIZZINESS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) STUMBLING OR FALLING
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) MUSCLE WEAKNESS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) DROPPING THINGS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) CHANGE IN HANDWRITING
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
ENERGY
1) DECREASE IN ENERGY LEVEL
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) FATIGUE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) LACK OF MOTIVATION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
MEMORY & COGNITION
1) MEMORY LOSS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) DIFFICULTY CONCENTRATING
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) MUSCLE WEAKNESS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) DIFFICULTY WITH PLANNING OR DECISION MAKING
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
MOOD
1) ANXIETY/STRESS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) MOOD SWINGS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) DEPRESSION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) CRYING SPELLS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) SUICIDAL THOUGHTS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
PAIN
1) UNEXPLAINED MUSCLE OR JOINT PAIN
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) BREAST TENDERNESS/SORENESS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) ABDOMINAL PAIN W/ DIARRHEA OR CONSTIPATION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) PELVIC PAIN
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) PELVIC PAIN ASSOC W/ MENSTRUAL CYCLE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
6) HEADACHES
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
7) MIGRAINE
MENSTRUAL
OTHER
SEXUALITY
1) PAIN WITH INTERCOURSE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) VAGINAL DRYNESS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) LOW OR ABSENT LIBIDO (DESIRE)
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) CHANGE IN SENSATION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) ORGASMIC DYSFUNCTION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
SENSORY CHANGES
1) DRY EYES
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) LOSS OF SENSE OF SMELL
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) SINUSITIS OR NASAL CONGESTION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) HEARING LOSS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) CHANGE IN VOICE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
SLEEP
1) DIFFICULTY FALLING ASLEEP
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) DIFFICULTY STAYING ASLEEP
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) WAKE FEELING TIRED
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) RECENT ONSET/WORSENING OF RESTLESS LEGS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) CHANGES IN DREAMING
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
TEMPERATURE REGULATION
1) HOT FLASHES
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) NIGHT SWEATS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) EXCESSIVE SWEATING
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) HEAT INTOLERANCE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) COLD INTOLERANCE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
URINARY SYSTEM
1) URINE LEAKAGE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) URGENCY
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
3) INCOMPLETE EMPTYING OF BLADDER
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
4) PAIN WITH URINATION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
5) NIGHT TIME WAKING TO URINATE
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
GENERAL MEDICAL
1) HEART PALPITATIONS
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
2) SWELLING AND/OR WATER RETENTION
None/Never
0
1
2
3
4
Severe/ Always
5
0 is None/Never, 5 is Severe/ Always
Submit
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