Women’s Health History Questionnaire

    Section 1 of 12

    Women’s Health History Questionnaire

    All personal information will be kept confidential and HIPAA compliant.

    Email *

    Full name *

    Date of birth (m/d/y) *

    Home address (include City, State, Zip) *

    Preferred phone number *

    Primary Care Physician (Name & Number)

    Local pharmacy (Name & Number) *

    Section 2 of 12

    Personal Health History

    Reason for your visit *

    Medical history (include medical diagnoses, previous surgeries, & hospitalizations)

    Have you been diagnosed with HIV and if so, date of diagnosis? *

    Currently prescribed medications (with dosing) & supplements

    Are you currently taking birth control and if so, which one and for how long? *

    Do you have any food/medication allergies and if so, please describe? *

    Section 3 of 12

    Lifestyle History

    Do you exercise and if so, how often?

    Briefly describe your eating habits (ex. breakfast, lunch, dinner, snacking, intermittent fasting, etc.):

    Briefly describe daily water, soda, & coffee consumption:

    How often do you drink alcohol per week?

    How often do you smoke/vape tobacco or nicotine per week?

    How often do you smoke/consume THC per week?

    Are you sexually active?

    Are You Currently Family Planning? *

    Any discomfort with intercourse and if so, please describe?

    Section 4 of 12

    Family Health History

    Is your father alive and if so, what is his age and medical history?

    If deceased, at what age and reason for death?

    Is your mother alive and if so, what is her age and medical history?

    If deceased, at what age and reason for death?

    If you have siblings, do they have any health conditions:

    If you have grandparents, do they have any health conditions:

    IMPORTANT:
    Any family history of breast cancer or endometrial/uterine cancer,
    * and if so, please explain *

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    Mental Health History

    Please rate your daily stress level

    If 7 or greater, please describe:






    Section 6 of 12

    Female Health History

    Please explain any "YES" answers

    Age at onset of menstruation

    Date of last menstruation

    (Length) Days of Menstrual Cycle

    Are You Experiencing Heavy Periods, Irregularity, Spotting, Pain, Or Discharge?

    Number of Pregnancies?

    Number of live births?

    Are you currently breastfeeding? *

    Previous history of D&C?

    Previous history of hysterectomy?

    Previous history of C-section/s?

    Date of last pap smear & mammogram (explain positive findings if any):

    Name/Contact information of your OB/GYN

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    Questions Suggestive of Low Testosterone

    Decreased libido (sex drive)?

    Feelings of depressed mood or depression?

    Fatigue or lethargy?

    Muscle weakness or loss of muscle mass?

    Decrease in strength or exercise performance?

    Weight gain?

    Loss of motivation?

    Loss of concentration?

    Section 8 of 12

    Questions Suggestive of Poly-Cystic Ovarian Syndrome (PCOS)

    Irregular or prolonged periods?

    Excess facial and/or body hair?

    Hair loss?

    Heavy cramping/bloating with menstruation?

    Cystic acne?

    Depression/anxiety/mood changes?

    Intractable fatigue?

    Low libido (sex drive)?

    Weight gain despite exercise and diet?

    Difficulty conceiving?

    History of high blood sugar or diabetes?

    History of high testosterone levels?

    History of ovarian cysts?

    Section 9 of 12

    Questions Suggestive of Estrogen Dominance

    Heavy or excessive periods?

    Difficulty sleeping?

    Excessive bloating/cramping around time of period?

    Low libido (sex drive)?

    Fatigue?

    Brain fog?

    Weight gain despite diet and exercise?

    Constipation?

    Fibrocystic breasts or breast tenderness?

    Hair loss?

    Hot flashes or temperature sensitivity?

    History of PMS?

    History of PCOS?

    History of uterine fibroids or endometriosis?

    Section 10 of 12

    Menopause Rating Scale (MRS)

    *Only for women who may be experiencing Peri-Menopause or Menopause

    Hot flashes, sweating

    Heart Palpitations

    Sleep problems (falling asleep, staying asleep, waking up early)

    Mood swings, depression, sadness

    Irritability, feeling nervous, agitated

    Anxiety

    Physical and mental exhaustion, brain fog, forgetfulness

    Decreased libido

    Urinary incontinence

    Vaginal dryness, painful intercourse

    Joint and muscle pain

    Section 11 of 12

    Other Symptoms Worth Noting

    Check areas where you are currently experiencing symptoms and list them below:

    If yes, please list symptoms here:

    Section 12 of 12

    Please indicate which medical services you may be interested in:

    (*Required Fields)
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