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
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
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) Allergies:
None
List Allergies:
6) Surgeries:
None
List Surgeries:
7) Hospitalizations (last 5 years):
None
List Hospitalizations:
8) Medical Problems:
None
List:
9) Medications and Supplements List Dose:
None
See Attached
List Medications:
10) Current Complementary or Alternative Therapy
None
List:
11) Weekly Exercise Routine
None
List:
12) Have you ever been touched in a way that makes you feel uncomfortable?
Yes
No
If yes would you like to discuss?
13) Have you ever controlled binge eating with vomiting or used a laxative to prevent weight gain?
Yes
No
14) 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:
15) Do you snore?
Yes
No
16) Have you ever been told you hold your breath during sleep?
Yes
No
17) Preferred Pharmacy:
18). Do you vape nicotine or other substances?
Yes
No
Back
Next
Menstrual History
1) When was your menstrual cycle?
2) At what age did your menstrual cycles begin?
3) Are you periods regular?
Yes
No
N/A
4) What is the length of time between your periods?
Days
Weeks
5) Are your periods?
Light
Medium
Heavy
6) Do you have pain with your periods?
No
Frequently
Occasionally
7) Do you have bleeding between your periods?
No
Frequently
Occasionally
8) Are you sexually active?
Yes
No
9) Are you using birth control?
Yes
No
Method
Reproductive History
1) How many times have you been pregnant?
Please describe below including miscarriage(s) or abortion(s)
2) Have you ever been concerned about infertility?
Yes
No
Family History
If living(L) please indicate state of health, if deceased(D) please indicate cause of death:
Rows
Age
Living
Deceased
State of health/ cause of death
Father
Mother
Brothers
Sisters
Have any of your Immediate family or Grandparents had the following?
Rows
Yes
No
Relation
Cancer:
a) Colon
b) Prostate
c) Uterine or Ovarian
d) Breast
Alzheimer's
Diabetes
Heart Disease
High Blood Pressure
Kidney Heart Disease
Osteoporosis
Thyroid Disease
Stroke
Auto Immune Disorder
Please list any special concerns you would like to discuss:
Patient Signature
Date
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Month
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Day
Year
Date
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
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