Date *
Date
Name *
Name
Birthday
Birthday
Address *
Address
Phone *
Phone
Do you use Tobacco? *
Do you use Alcohol? *
Do you use Caffeine? *
Do you Exercise? *
Please list any allergies and describe the reaction that occurred.
Please list all non-prescription medications that you are taking. (include vitamins, herbals, and supplements)
Please list any conditions/diseases that you have been diagnosed with or suffer from. (examples: heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc.)
Medication Name and Strength Date Started How Ofter per Day
Date Started Date Stopped Reason
If Yes, Date of Surgery
If Yes, Date of Surgery
If Yes, Date of Surgery?
If Yes, Date of Surgery?
Please list the Family Members
Have you had a Mammography Test? *
Date of Exam
Date of Exam
Have you had a Pap Smear Exam? *
Date of Exam
Date of Exam
Have you had a Bone Density Exam? *
Date of Exam
Date of Exam
Hot Flashes
Night Sweats
Vaginal Dryness
Incontinence
Bleeding Changes
Fibrocystic Breast
Weight Gain
Fluid Retention
Dry Skin / Hair
Hair Loss
Anxiety
Depression
Mood Swings
Irritability
Headaches
Breast Tenderness
Cramps
Difficulty Falling Asleep
Difficulty Stay Asleep
Fatigue
Loss of Memory
Foggy Thinking
Acne
Arthritis
Decreased Sex Drive
Harder to Reach Climax
Stress
Doctor Phone Number
Doctor Phone Number
Doctor's Address
Doctor's Address