Women’s Health Questionnaire Women’s Health Questionnaire "*" indicates required fields Step 1 of 15 6% X/TwitterThis field is for validation purposes and should be left unchanged.Personal InformationFull Name*Email* Phone number* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth* MM slash DD slash YYYY Gender* Male Female Other HeightFeet*Inches*Weight* How Did you hear about us?Emergency Contact Name & Phone Name*Phone*Consent to receive automated messages/reminders: Texts Calls E-mails Marital Status* Married Single Divorced Other Other Status*Living Situation* Spouse Alone Partner Parents Children Other Other Living Situation*How would you rate your current general health?* Excellent Good Fair Poor Medical HistoryDo you have Current or past history of any of the following?(Check all that apply) High blood pressure Diabetes (Type 1 or 2) High cholesterol Heart disease Stroke Sleep apnea Depression or anxiety Thyroid disorder Hashimoto's Thyroiditis Fibromyalgia Kidney or liver disease Seizure disorder Cancer Arthritis MTHFR gene mutation Hormone Imbalance Blood clot(DVT/PE) Varicose Veins Osteoporosis Eating disorder Drug/alcohol abuse (past or current) Heart palpitations Ventricular heart problems Arrhythmia Pacemaker IBS Constipation Diarrhea GERD Heartburn Pancreatitis Diverticulitis Bowel blockage Other Other*Type of Cancer*Food/Medication Allergies?* No Yes List of Allergies* Pregnant or breastfeeding? No Yes Current medications or supplements?* No Yes Current medications or supplements List*Surgical History* No surgeries Yes Type / Date of Surgery* Family Medical History (Check applicable family members only)FatherMotherSiblings Meals/day?* 1 2 3 More Snacking?* Rarely Sometimes Often Exercise frequency?* Never 1–2x/week 3–5x/week Daily Sleep/night?* <5 hrs 5–6 hrs 7–8 hrs >8 hrs Alcohol use?* No Occasionally Frequently Drinks / Week*Tobacco use?* No Yes Packs/day* Recreational/illicit drug use (past or present)?* No Yes Type*Have you had your cholesterol checked?* No Yes Date* MM slash DD slash YYYY Result* Gynecological HistoryHave you had a mammogram?* No Yes Date* MM slash DD slash YYYY Results*Have you had a bone density scan?* No Yes Date* MM slash DD slash YYYY Results*Pelvic Exam* No Yes Date* MM slash DD slash YYYY Results*Last Pap Smear* No Yes Date* MM slash DD slash YYYY Results*Abnormal Pap Smear?* No Yes Treatment*Trying to get pregnant?* No Yes Sexually active?* No Yes Current birth control methodProblems with it?How long?Past birth control & problemsAge of first period*Last periodCycle length*DaysFlow*DaysAmount of bleeding* Normal Heavy Light Other Other Amount*Menstrual Cramp Severity* Mid Moderate Severe DurationPremenstrual symptomsStartEndChanges in cycle?* No Yes Explain*Bleeding between periods?* No Yes When*Pelvic pain, pressure, fullness?* No Yes Describe* Vaginal discharge or itching?* No Yes Describe*Treatment?*Age at first pregnancy# of full-term pregnanciesPregnancy problems?Miscarriages or abortions?* No Yes Ovary removal?* No Yes Ovaries remain?* No Yes Tubal ligation?* No Yes When?*Hysterectomy?* No Yes When?* General Health Evaluation Severity - None-0 ____ EXTREME- 10Sleep Disruptions*012345678910Fatigue*012345678910Vaginal Dryness*012345678910Irritability*012345678910Nervousness*012345678910Breast Tenderness*012345678910Hot Flashes*012345678910Dry Skin*012345678910Mood Swings*012345678910Arthritis*012345678910Loss of Recent Memory*012345678910Weight Gain*012345678910Decreased Sex Drive*012345678910Depression*012345678910Fluid Retention*012345678910Headaches*012345678910Night Sweats*012345678910Hair Loss*012345678910Harder to Reach Climax*012345678910Bladder Symptoms*012345678910Other*012345678910Date of Form Completion* MM slash DD slash YYYY Consent* I confirm this information is accurate. I agree to this consent. My name represents my signature.
