Women’s Consultation Form

1. Date
2. Referred By
3. Name
4. Email
5. Address
6. City
7. State
8. Zip
9. Home
10. Cell
11. Work
12. Age
13. D.O.B
14. Social Security
15. Martial Status
16. Occupation
17. Date of Last Menstrual Period
18. No. of pregnancies
19. No. of deliveries
20. Reason for Visit
21. Please check all applicable and explain
22. Excessive Weight Hepatitis Mental Health/Depression Chronic Fatigue Syndrome HIV Positive Mitral Valve Prolapse Colitis Hypertension Multiple Sclerosis Diabetes Hypothyroidism Chronic Yeast Infection Elevated Cholesterol Irrit. Bowel Sydrome Seizures Elevated Triglycerides Kidney Disease Sleep Disorders Heart Disease Stroke Skin Complaints
23. Health Maintenance (Date last done)
24. Bone Density
25. MMG
26. Pap
27. Lipid Profile
28. Flex Sigmoidoscopy
29. Medical Problems (Explained from above)
30. Name and number of Primary Care Physician
31. Current Medications/Supplements
32. Birth Control Method
33. Hormones
34. Do you have any drug allergies?
35. Yes No
36. If yes, give reaction medication and reaction
37. Do you exercise?
38. Yes No
39. What kind?
40. How Often?
41. Do you smoke?
42. Yes No
43. How much?
44. How Long?
45. Do you use alcohol?
46. Yes No
47. How much?
48. How Long?
49. Have you had a major illness/hospitalization/surgery?
50. Yes No
51. Explain
52. Is there a family history of (Please check)
53. Colon Cancer Ovarian Cancer Diabetes Breast Cancer High Blood Pressure Heart Disease Other
54. Other
55. Are you interested in our other services:
56. Nutritional testing Laser Rejuvenation Cellulite Treatment Weight Management Skin Care Mineral Makeup Allergy Testing Laser Skin Tightening Facial Treatments Massage/ PT Laser Hair Removal Laser Hair Regrowth
57. Children (Name and age of children)
58. Name 1
59. Age
60. 2
61. Age
62. 3
63. Age
64. 4
65. Age
66. 5
67. Age
68. 6
69. Age
70. Family History (Medical Problem(s))
71. Father- alive or deceased?
72. Age
73. Mother- alive or deceased?
74. Age
75. Brothers/Sisters
76. Age
77. Brothers/Sisters
78. Age
79. Brothers/Sisters
80. Age
81. Brothers/Sisters
82. Age
83. REVIEW OF SYMPTOMS
84. Heart
85. Do you ever feel your heart skip a beat?
86. Yes No
87. How often?
88. For how many years?
89. Do you have chest pain?
90. Yes No
91. How often?
92. For how many years?
93. Is the pain sharp / stabbing / dull / aching?
94. Yes No
95. Does it radiate to your neck, back, or shoulders?
96. Yes No
97. How long does the pain last?
98. Do you feel like you are going to pass out?
99. Yes No
100. Gastrointestinal System
101. Do you have abdominal cramping, bloating, excessive belching or intestinal gas?
102. Yes No
103. How often?
104. x/week
105. How long?
106. Urinary Tract
107. Have you ever had bladder infections / kidney infections?
108. Yes No
109. How many x/year?
110. For how many years?
111. Have you ever had kidney stones?
112. Yes No
113. How many times?
114. Year of last episode
115. Do you have burning upon urination?
116. Yes No
117. Do you have increased frequency of urination?
118. Yes No
119. Yeast/Skin Fungus
120. Have you ever had a vaginal yeast infection?
121. Yes No
122. How many times?
123. How many years?
124. Between what years?
125. and
126. Environmental Allergies
127. Do you have environmental allergies such as: pollen, mold, cat, or dog?
128. Yes No
129. Have you had an allergy test performed?
130. Yes No
131. If yes, date:
132. Please list allergies below
133. 1
134. 6
135. 2
136. 7
137. 3
138. 8
139. 4
140. 9
141. 5
142. 10
143. Thyroid
144. Have you been diagnosed with a thyroid disorder?
145. Yes No
146. Year diagnosed
147. Were you diagnosed with hyperthyroidism?
148. Yes No
149. Were you diagnosed with hypothyroidism?
150. Yes No
151. Did you ever take thyroid medication?
152. Yes No
153. What year did you quit?
154. Name of medicine
155. Dose
156. mg
157. Malaise/Fatigue
158. Do you feel you should have more energy?
159. Yes No
160. What is your average energy level on a scale of 0 to 10 with 10 meaning brimming with energy and 1 or 2 meaning the inability to get out of bed?
161. ENERGY LEVEL 0-10
162. For how many years?
163. Hair Condition
164. Do you have coarse or fine hair?
165. Yes No
166. For how many years?
167. Have you ever had significant hair loss?
168. Yes No
169. How long? months
170. years
171. Weight
172. Have you had significant weight gain?
173. Yes No
174. How many pounds?
175. Since what year?
176. Do you have difficulty losing weight?
177. Yes No
178. How long?
179. Are you interested in medical weight loss?
180. Yes No
181. Mood
182. Do you ever feel discouraged, blue or depressed more than 10% of the time?
183. Yes No
184. What percent of the time?
185. For how many years?
186. Have you ever taken anti-depressants?
187. Yes No
188. Which one(s)?
189. Between what ages?
190. and
191. Skin
192. Do you have dry skin?
193. Yes No
194. For how many years?
195. Sleep
196. Do you have insomnia or restless sleep?
197. Yes No
198. How many years?
199. Do feel tired after a full night's sleep?
200. Yes No
201. How many years?
202. Do you have afternoon fatigue?
203. Yes No
204. How many hours of sleep do you require?
205. MENSTRUAL HISTORY - PREMENOPAUSAL QUESTIONS
206. Pregnancy
207. Date of last normal menstrual period?
208. At what age did you enter puberty?
209. How many pregnancies?
210. live births?
211. miscarriages?
212. Date of last child’s birth
213. Your age then?
214. Did you have difficulty becoming pregnant?
215. Yes No
216. Did you ever receive infertility treatment?
217. Yes No
218. What kind?
219. Birth Control
220. Have you had bilateral tubal ligation?
221. Yes No
222. If yes, when?
223. Are you currently using an IUD?
224. Yes No
225. Have you ever taken Depo- Provera?
226. Yes No
227. Did you ever take birth control pills?
228. Yes No
229. If yes, for how long? months
230. years
231. Date you discontinued BCP
232. Are you currently taking any female hormones (progesterone or estrogen)?
233. Yes No
234. If yes, which ones?
235. For how long?
236. Pap Smear
237. Have you had an abnormal pap smear?
238. Yes No
239. If yes, when?
240. Was your most recent pap smear normal?
241. Yes No
242. Date
243. Menstrual Periods
244. Do your menstrual periods occur at the same time each month?
245. Yes No
246. If no, what is the shortest number of days between periods?
247. What is the longest number of days between periods?
248. How long have your menstrual cycles been irregular? months
249. years
250. Were your menstrual cycles ever regular?
251. Yes No
252. How many days do your periods last? days
253. Are your periods heavier or lighter than in the past?
254. Yes No
255. If yes, when did they change?
256. Do you have intermenstrual bleeding that occurs between your normal periods?
257. Yes No
258. If yes, for how long has this occurred? months
259. years
260. Premenstrual Syndrome
261. Do you have breast tenderness prior to your period?
262. Yes No
263. If yes, how many days prior to your period does it begin? days
264. For how long has this occurred? months
265. years
266. Do you have mood swings to your period?
267. Yes No
268. If yes, how many days prior to your period does it begin? days
269. For how long has this occurred? months
270. years
271. Do you have fluid retention prior to your period?
272. Yes No
273. If yes, how many days prior to your period does it begin? days
274. For how long has this occurred? months
275. years
276. Do you have weight gain prior to your period?
277. Yes No
278. Approximately how many pounds do you gain prior to your periods? lbs
279. For how long has this occurred? months
280. years
281. Do you crave sweets or bread products prior to your periods?
282. Yes No
283. Do you develop headaches (not migraine) prior to your periods?
284. Yes No
285. If yes, how many days prior to your period do they begin? days
286. For how long has this occurred? months
287. years
288. Do you have menstrual cramps?
289. Yes No
290. If yes, for how many days?
291. Do you experience hot flashes?
292. Yes No
293. For how long? months
294. years
295. Do you have night sweats?
296. Yes No
297. For how many years?
298. Have any of the above symptoms ever caused you to miss work or school, or cause you to be unable to do daily functions?
299. Yes No
300. Estrogen Dominance
301. Do you have fibrocystic breast disease?
302. Yes No
303. how long? months
304. years
305. Have you ever had endometriosis?
306. Yes No
307. how long? months
308. years
309. Do you have uterine fibroids?
310. Yes No
311. How many times?
312. Which side?
313. Left Right
314. Have you developed dark hair on your face?
315. Yes No
316. How long ago did it begin? months
317. years
318. Have you developed dark hair on your breasts?
319. Yes No
320. How long ago did it begin? months
321. years
322. Have you had a decrease in sexual desire?
323. Yes No
324. For how long? months
325. years
326. Have you ever had pain or discomfort during or after intercourse?
327. Yes No
328. Due to vaginal dryness?
329. Yes No
330. For how long? months
331. years
332. Bone Density
333. Have you ever been diagnosed with osteoporosis?
334. Yes No
335. Recurrent Medications
336. Do you currently take prescription medication?
337. Yes No
338. Please list the strength, times/day taken, and number of years taken:
339. 1
340. 6
341. 2
342. 7
343. 3
344. 8
345. 4
346. 9
347. 5
348. 10
349. Do you currently take vitamins or supplements?
350. Yes No
351. Please list the strength, times/day taken, and number of years taken:
352. 1
353. 6
354. 2
355. 7
356. 3
357. 8
358. 4
359. 9
360. 5
361. 10
362. Loss Questionnaire
363. What are your weight loss goals?
364. What weight loss methods have you tried previously?
365. How much weight did you lose? Are you happy with the results?
366. Please list your food intake on a typical day:
367. BreakfastSnackLunchSnackDinner
368. Time:
369. Time:
370. Time:
371. Time:
372. Time:
373. Food:
374. Food:
375. Food:
376. Food:
377. Food:
378. Food:
379. Food:
380. Food:
381. Food:
382. Food:
383. Food:
384. Food:
385. Food:
386. Food:
387. Food:
388. Calories:
389. Calories:
390. Calories:
391. Calories:
392. Calories:
393. Please list your exercise routine for a typical week. Please list duration under each day:
394. MonTuesWedThursFriSatSun
395. Cardio:
396. Cardio:
397. Cardio:
398. Cardio:
399. Cardio:
400. Cardio:
401. Cardio:
402. Weights:
403. Weights:
404. Weights:
405. Weights:
406. Weights:
407. Weights:
408. Weights:
409. Pilates:
410. Pilates:
411. Pilates:
412. Pilates:
413. Pilates:
414. Pilates:
415. Pilates:
416. Yoga:
417. Yoga:
418. Yoga:
419. Yoga:
420. Yoga:
421. Yoga:
422. Yoga:
423. Other:
424. Other:
425. Other:
426. Other:
427. Other:
428. Other:
429. Other:

 

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