STEAM HERBS Screening Form
*Please note all responses are kept strictly confidential and adhere to HIPAA Compliance. To best serve you, please answer all questions thoroughly and truthfully.
Full Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
*
example@example.com
Date of Birth
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Month
-
Day
Year
Date
Referred By
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Emergency Contact
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List any issues, symptoms and. or conditions that you are dealing with and wish to address. Please be specific.
When did you first notice major complaints?
What brought it on?
Has there been a medical diagnosis?
Yes
No
By Whom?
Reproductive Health History
What was the first day of your last period?
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If they have stopped, when?
How often do your periods come?
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How long do they last?
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For how long?
Are you under treatment for Infertility?
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Yes
No
If so, describe current treatment: (I.V.F, I.U.I)
Describe past treatments:
Pregnancy
Are you pregnant or trying to conceive?
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Yes
No
How many pregnancies have you had?
Number of Deliveries?
Terminations/ When?
Miscarriages / When?
Complications:
Check the symptoms/conditions that you're CURRENTLY experiencing:
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Abnormal Pap Smears
Acne
Adhesions/Scar Tissues
Amenorrhea (missed periods)
Anxiety/Depression
Bladder Infections
Bloating/ Water Retention
Cancer (especially of the reproductive area)
Chronic Miscarriage
Clotting
Dark Blood at the beginning or end of cycle
Dysmenorrhea (painful periods)
Edema in legs
Endometrosis
Excessive Bleeding
Failure to Ovulate
Frequent Urination
Headaches or Migraines with period
Heaviness in Pelvis with period
Hemorrhoids
Hot Flashes
Incontinence
Infertility / Fertility Issues
Irregular Cycles (early or late)
Irregular Ovulation
Irritability/ Mood Swings
Low Back Pain with period
Low Libido
Ovarian Cysts
Painful Intercourse
Painful Ovulation
PMS
Polycystic Ovarian Syndrome (PCOS)
Restless Legs
Sexually Transmitted Disease
Spotting
Uterine Fibroids
Uterine Infections
Uterine Polyps
Uterine Prolapse
Vaginal Discharge/Odor
Vaginal Dryness
Vaginal Infections
Varicose Veins
Womb Trauma
Other symptoms not listed above:
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List the symptoms/conditions that you've experienced in the PAST.
*
Do you have any known contagious disease currently?
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Yes
No
If yes, please list:
Please list diseases prevalent on both your mother and father sides of your family: (i.e. diabetes, high blood pressure, cancers)
Do you have a medical diagnosis of any mental, personality, or social disorders? (i.e. Obsessive Compulsive Disorder, Anxiety Disorder, Bipolar Disorder, Hoarding, Schizophrenia)
Yes
No
If Yes, please explain
What medications (prescribed or over the counter), herbs, vitamins, supplements, etc..., are you currently taking? (also list why you are taking them)
Submit
Should be Empty: