Women's Health Questionnaire
Full Name
*
First Name
Last Name
E-mail Address
*
example@example.com
Contact Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Date of Birth
*
Please select a day
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Day
Please select a month
January
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Month
Please select a year
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Year
Reason(s) for Your Visit
Please describe the most important goal(s) you hope to achieve during this visit.
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Past Medical and Surgical History
Have you ever been told you have a medical diagnosis or illness? (diabetes, high blood pressure, etc.)? If so, please describe.
Have you ever been hospitalized overnight or had surgery? If so, please describe.
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Family History
What health conditions run in the family?
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Reproductive Health History
Last Menstrual Cycle: If you have menstrual cycles, please choose the first date of bleeding during your most recent menstrual cycle.
-
Month
-
Day
Year
Date
Contraception
Are you currently using a birth control method to prevent pregnancy and/or regulate your menstrual cycle?
Yes
No
If yes, please indicate which of the following you use:
Birth Control Pills
Intrauterine Device
Birth Control Patch
Contraceptive Implant
Vaginal Ring
Depo Provera Shot
Diaphragm/CAYA
Withdrawal Method
Natural Family Planning
Condoms
Other
Pregnancy History
Have you ever been pregnant?
Yes
No
If yes, how many times have you been pregnant?
If you had any pregnancy complications, please describe them here.
Pregnancy Complications
Prior Fertility Testing or Treatment
Have you ever had infertility testing?
Yes
No
If yes, please choose any of the following testing that you (or your partner) have undergone for evaluation of fertility.
Labs (blood or urine) testing
Imaging (such as ultrasound)
Hysteroscopy
Laparoscopy
Semen Testing
Other
Have you ever had fertility treatment?
Yes
No
If yes, please choose any of the following treatments that you have undergone for treatment of fertility.
Fertility medications
In Vitro Fertilization
Intrauterine Insemination
Stress Reduction Techniques
Other
Have you ever been told that you have PCOS (Polycystic Ovarian Syndrome)?
Yes
No
Have you ever been told that you have Endometriosis?
Yes
No
Have you ever been diagnosed with a Sexually Transmitted Infection?
Yes
No
If yes, please choose any of the following that apply.
Chlamydia
Gonorrhea
Genital HSV
HIV
Syphilis
Trichomonas
HPV
Hepatitis
Other
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Medications
Please list all medications that you take on a regular basis, including over the counter medications and supplements.
Allergies
Please list any medications or food allergies.
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Social History
Who lives at home with you?
Are you employed? If so, please state your job title.
What is the highest level of education you achieved?
Elementary School
High School
College
Graduate/Professional School
Other
Are there any major stressors in your life recently? If so, please describe.
Do you use tobacco products?
Yes
No
Former smoker
Please describe what type of tobacco products you use, and how frequently.
Do you drink alcohol?
Yes
No
Please describe how many drinks of alcohol you have in an average week.
Do you use any other substances?
Yes
No
Please describe any other substance use.
Have you ever been informed of an exposure to environmental toxins?
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Review of Systems
Please tell us about any of the following symptoms you may have experienced recently. Select all that apply. If you prefer not to answer, these can also be discussed at your visit.
Additional Symptoms:
Irregular or absent periods
Painful periods
Excessively long periods
Vaginal bleeding between periods
Trouble getting pregnant
Hot Flashes
Trouble Sleeping
Night Sweats
Hair loss
Excess hair growth (chin, face)
Acne
Decrease Libido
Sexual problems
Weight gain/loss
Abdominal Bloating
Brain Fog or Memory issues
Irritability
Other
Is there anything else you would like us to know prior to your visit? If so, please provide that detail below.
Submit
General Physical Symptoms:
Chest pain
Trouble Breathing
Bladder problem (frequent infections/incontinence/other)
GI problem (constipation/diarrhea/other)
Appetite changes
Pain
Heartburn
Limited Mobility
Eye problem
Trouble hearing
Skin problem
Anxiety/Depression/Mood swings
Other
Should be Empty: