Female Health Assessment Questionnaire Step 1 of 4 25% Name(Required) First Last Email(Required) Date(Required) MM slash DD slash YYYY Phone(Required)SymptomsPlease mark the appropriate box for each symptom you may be experiencing.Physical Exhaustion (fatigue, lack of energy, stamina or motivation)(Required) None Mild Moderate Severe Very Severe Sleep Problems (difficulty falling asleep or sleeping through the night)(Required) None Mild Moderate Severe Very Severe Irritability (mood swings, feeling aggressive, angers easily)(Required) None Mild Moderate Severe Very Severe Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)(Required) None Mild Moderate Severe Very Severe Decline in drive or interest (loss of “zest for life,” feeling down or sad)(Required) None Mild Moderate Severe Very Severe Joint and muscular symptoms (poor recovery after workout, inability to add muscle, joint pain, muscle weakness)(Required) None Mild Moderate Severe Very Severe Difficulties with memory (concentration, finding the right word, or retaining information)(Required) None Mild Moderate Severe Very Severe Vaginal dryness or difficulty with sexual intercourse(Required) None Mild Moderate Severe Very Severe Sexual Problems (change in desire, activity, orgasm and/or satisfaction)(Required) None Mild Moderate Severe Very Severe Sweating (night sweats or increased episodes of sweating)(Required) None Mild Moderate Severe Very Severe Hot Flashes (burst that starts in chest and lasts for short duration)(Required) None Mild Moderate Severe Very Severe Hair loss, rapid or thinning(Required) None Mild Moderate Severe Very Severe Feeling cold all the time, having cold hands or feet(Required) None Mild Moderate Severe Very Severe Headaches or migraines (increase in frequency or intensity)(Required) None Mild Moderate Severe Very Severe Weight (difficulty losing weight despite diet/exercise)(Required) None Mild Moderate Severe Very Severe Bladder problems (difficulty in urinating, increased need to urinate)(Required) None Mild Moderate Severe Very Severe Other symptoms or unique health circumstances to take into consideration: FEMALE PATIENT QUESTIONNAIRE & HISTORYName(Required) First Last Date(Required) MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Age(Required)Weight(Required)Occupation(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhonePreferred Contact PhoneMay we send messages via text regarding appts to your cell?(Required) Yes No Email May we contact you via email?(Required) Yes No In case of emergency contact:(Required)Relationship(Required)Home PhoneCell PhoneWork PhonePrimary care physician’s namePhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status(Required) Married Divorced Widow Living with Partner Single Check OneIn the event we cannot contact you by the means you have provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.Name First Last RelationshipHome PhoneCell PhoneWork PhoneSocialSocial I am sexually active I want to be sexually active I have completed my family I have not completed my family My sex life has suffered I have not been able to have an orgasm, or it is very difficult. I do not want to be sexually active HabitsI smoke(Required) Yes No How Many Per Day?I use e-cigarettes(Required) Yes No How Many Per Day?I use caffeine(Required) Yes No How Many Per Day?I drink alcohol(Required) Yes No How Many Per Week?I drink more than 10 alcoholic beverages a week(Required) No Yes Drug allergiesDrug allergies(Required) Yes No Please explainHave you ever had any issues with local anesthesia?(Required) Yes No Have you ever had any issues with local anesthesia?(Required) Yes No Medications currently takingCurrent hormone replacement?(Required) Yes No If yes, what?Past hormone replacement therapyFamily HistoryFamily History Heart diseas Diabetes Osteoporosis Alzheimer’s/dementia Breast cancer Other If other, please listPertinent medical/surgical historyHistory Breast cancer Uterine cancer Ovarian cancer Polycystic ovaries / PCOS Acne Excess facial / body hair Infertility Endometriosis Epilepsy or seizures Fibrocystic breast or breast pain Uterine fibroids Irregular or heavy periods Menstrual migraines Hysterectomy with removal of ovaries Partial hysterectomy (uterus only) Oophorectomy removal of ovaries Birth Control Method Menopause Hysterectomy Tubal ligation Birth control pills Vasectomy IUD Infertility Other If other, please list Medical History High blood pressure or hypertension Heart disease Atrial fibrillation or other arrhythmia Blood clot and/or pulmonary embolism Depression/anxiety Chronic liver disease (hepatitis, fatty liver, cirrhosis) Arthritis Hair thinning Sleep apnea High cholesterol Stroke and/or heart attack HIV or any type of hepatitis Hemochromatosis Psychiatric disorder Thyroid disease Lupus or other autoimmune disease Other If other, please list </noscript><iframe class="lazy" style='display:none;width:0px;height:0px;' src="" data-src='about:blank' name='gform_ajax_frame_5' id='gform_ajax_frame_5' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'>
