Print form below, fill out and bring with you to your office visit:

Name:________________________________________________

Birth Date:_______________ Today's Date:__________________

Current Health Problems/Concerns:
________________________________________________________________________

Current medications, prescription (i.e. hormones) or over-the-counter:
________________________________________________________________________


General Health (check any that apply):
Chronic Fatigue
Headaches		 Irritability
Bone Pain		 Shortness of breath
Memory Fails


Gynecological History:

Date of last gynecological exam (PAP, mammogram)_______ Results:

_____________________________________________________________________________

Date of last menstrual cycle_________ Length of Cycle___________

Interval of time between cycles__________

Any recent changes in normal menstrual flow_____________________

Age of first period___________ Form of birth control____________

Number of children____________ Number of pregnancies______________

C-section______ Surgical menopause, date___________________

Describe surgery
_____________________________________________________________________________

Check any that apply:
Endometriosis
Infertility
Fibrocystic Breasts
STD		 Fibroids/Ovarian Cysts
Reproductive Cancer
Pelvic Inflammatory Disease
Genital Herpes		 Vaginal Infections
Vaginal Candiasis


Family Medical History (check any that apply):
Breast or Other Cancers
Cardiovascular Disease
Osteoporosis
Obesity
 Alcoholism
Mental Illness/Depression
Alzheimer's
Diabetes
 Arthritis
Stroke


Lifestyle & Diet:

Rate the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest):
_____________________________________________________________________________

Identify the major causes:
_____________________________________________________________________________


Do You Eat (check any that apply):

Sweets, sodas, ice cream
Fried foods
Whole grains, legumes, cereals
Fruits/Vegetables

List your 4 favorite foods:
_____________________________________________________________________


Do You (check any that apply):
Diet frequently
Skip Meals
How many meals do you eat per day?
___________
Dine out regularly
Use tobacco/smoke cigarettes
How many cigarettes per day?
___________
Exposed to passive smoke
Eat chocolate		 Drink coffee
# cups per day:____
Strong____
Mild____
Decaffeinated____
Drink alcoholic beverages
How many ounces per day/per week?
___________________
Preference_________________
Exercise Daily
How many times per week/activity?
________________________________


Do you restrict your intake of or avoid completely
(check any that apply):
Dietary fat
Dairy products		 Animal protein
Salt		 Fiber
All animal foods


Check the symptoms you experience regularly
one to two weeks before your period:

Part 1:

1. Anxiety
2. Irritability
3. Nervous tension
4. Aggressive or hostile toward family/friends
5. Engage in self destructive behavior
6. Weight gain
7. Water retention
8. Abdominal bloating
9. Tender, swollen and/or painful breasts
10. Breast lumps increase in size and tenderness
11. Discharge from nipples
12. Craving for sweets		 13. Increased appetite
14. Heart palpitations
15. Fatigue
16. Headaches
17. Shaky or clumsy
18. Depressed
19. Withdrawn
20. Confused
21. Forgetful
22. Insomnia/difficulty sleeping


Check the symptoms and/or behaviors that occur
during your period with a frequency or intensity
that affects your daily activities:

Part 2:

1. Cramping in lower abdomen or pelvic area
2. Sharp intermittent pain
3. Dull aching pain
4. Upset stomach
5. Diarrhea
6. Nausea or vomiting
7. Low back aches
8. Headaches
9. Difficulty concentrating		 10. Accident prone
11. Unusual fatigue (take naps)
12. Decreased productivity
13. Weight gain
14. Painful and/or swollen breasts
15. Irritability
16. Mood Swings
17. Depression
18. Painful intercourse


Check off any of the following statements that describe your menstrual cycle, energy level or reproductive function:

Part 3:

1. Heavy prolonged menstrual bleeding/clotting
2. Menstrual bleeding that lasts longer than 5 days
3. Absence of periods for 3 months or more
4. Vaginal itching, burning, dryness
5. Menstruation that occurs too frequently (every 21-24 days)
6. Irregular periods (once every three to six months)
7. Frequently skip periods
8. Menstrual cycle every 36 days or longer
9. Unusually light or heavy periods
10. Unusually light menstrual flow - "spotting"
11. Menses last three days and are light
12. Bleeding or spotting between periods
13. Bleeding between periods is light - "staining"
14. Bleeding between periods is heavy and/or clots
15. Abnormal vaginal discharge
16. Frequent urination


Check any of the following symptoms if they occur throughout the month with an intensity or frequency that affects your ability to perform your daily activities or feel good about yourself:

Part 4:

1. Decline of vital energy and sense of well-being
2. Hot flashes
3. Night sweats
4. Spontaneous sweating
5. Chills
6. Depressed
7. Irritable
8. Anxiety
9. Anger
10. Mood swings
11. Headaches
12. Forgetful
13. Difficulty concentrating
14. Difficulty sleeping		 15. Urinary problems
16. Vaginal problems
17. Dry skin
18. Bleeding between periods
19. Irregular periods
20. Stopped menstruation
21. Joint and muscle pain
22. Change in sexual desire
23. Difficulty with orgasm
24. Painful intercourse
25. Loss of muscle tone
26. Vaginal bleeding any time
27. Vaginal bleeding after sex
28. Vaginal discharge


Additional Comments:
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