Women's Consultation Form

Date Date / MM / DD YYYY
Name Name First Last
Age
Height
Weight
Birthdate Birthdate / MM / DD YYYY
Street Address
State
City
Zip Code
Email
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Fax Fax - ### - ### ####
Occupation
What is your greatest need or problem? (List the most important; then list other issues in order of importance):
Your current medical conditions or diagnoses:
Drug allergies:
Allergies to food, pollens, environment, etc:Allergies to food, pollens, environment, etc:
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:
Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:
Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:
If you are you currently taking medication for a thyroid condition, which one and dose?
Have you ever had a bone density scan?
When?
Results
Do you use tobacco products?
What?
How much?
For how long?
Do you use alcohol products?
What?
How much?
For how long?
Do you use caffeine products?
What?
How much?
Do you use recreational drugs?
What?
How much?
How much water do you drink in one day (24 hr)?
Is your drinking water from a:
Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):
When was your last general medical exam: When was your last general medical exam: / MM / DD YYYY
When was your last pelvic exam: When was your last pelvic exam: / MM / DD YYYY
Have you ever had an abnormal Pap?
When?
Treatment
At what age was your First Period (menarche)?
When was your most recent or last period (LMP):
Do you still have your period?
If Yes, how many days from the start of one period to the start of the next?
Number of days of flow:
Amount of bleeding:
Describe any cramping or pain you may have:
Do you have pain at any other time in your cycle?
Where, when, how long?
Any current changes in your normal cycle?
Any bleeding between periods (IMB):
When and describe:
What were your periods like as a teenager?
Have you ever had Premenstrual Symptoms (PMS), please describe:
How long have you had PMS symptoms?
Starting and ending when:
If your periods have ever been difficult, irregular, or abnormal in any way, please describe:
If you are you currently having any pelvic pain, pressure, or fullness, describe:
Describe any recent unusual vaginal discharge or itching:
Treatment for any of above:
Have you had any of the following surgeries?
Tubes tied (tubal ligation)?
When?
At what age?
Uterus removed (hysterectomy)?
When?
Why?
Ovaries removed (oophorectomy)?
If Yes or PART, What?
When?
Why?
Were there any problems associated with the surgery or removal of any of these organs?
Has your doctor diagnosed menopause, or told you that you are in menopause?
If Yes, at what age?
If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed?
Have you ever been pregnant?
Are you trying to get pregnant?
What was your age at your first pregnancy?
How many times have you been pregnant (gravida)?
How many pregnancies resulted in the birth
of living children (para)?
Were there any problems?
Any interrupted pregnancies (miscarriages or abortions)?
Current birth control method:
How long:
Any problems?
Have you ever used any of the following birth control methods:
Oral Contraceptives (Birth Control Pills)
Total months/years used:
Describe any side effects to Birth Control Pills:
Intra-Uterine Device (IUD)
Problems?
When was your last mammogram?
Results:
Do you examine your breasts monthly?
Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details:
Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions?
If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:
CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.

0 = None (symptom not present)
1 = Mild (present but not distressing)
2 = Moderate (distressing, but not interfering with daily life)
3 = Severe (very distressing, interferes with daily life)

If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.
Hot flushes

Hot flushes 0 1 2 3
Night sweats

Night sweats 0 1 2 3
Light-headed feelings/dizziness

Light-headed feelings/dizziness 0 1 2 3
Headaches

Headaches 0 1 2 3
Sleep disorders/Sleeplessness

Sleep disorders/Sleeplessness 0 1 2 3
Unusual tiredness/Fatigue

Unusual tiredness/Fatigue 0 1 2 3
Irritability

Irritability 0 1 2 3
Depression

Depression 0 1 2 3
Anxiety/Tension/Nervousness

Anxiety/Tension/Nervousness 0 1 2 3
Mood swings/Mood changes

Mood swings/Mood changes 0 1 2 3
Confusion/Difficulty concentrating

Confusion/Difficulty concentrating 0 1 2 3
Forgetfulness/Short-term memory loss

Forgetfulness/Short-term memory loss 0 1 2 3
Angry outbursts/Arguments/ Violent tendencies

Angry outbursts/Arguments/ Violent tendencies 0 1 2 3
Crying easily

Crying easily 0 1 2 3
Backache

Backache 0 1 2 3
Joint pains

Joint pains 0 1 2 3
Muscle pains

Muscle pains 0 1 2 3
Muscle cramps/spasms

Muscle cramps/spasms 0 1 2 3
Problems with wound healing time

Problems with wound healing time 0 1 2 3
Acne/Pimples/Skin flushing

Acne/Pimples/Skin flushing 0 1 2 3
New facial hair

New facial hair 0 1 2 3
Dry skin/Dry hair

Dry skin/Dry hair 0 1 2 3
Crawling feeling under skin

Crawling feeling under skin 0 1 2 3
Frequent Urinary Tract Infection (UTI)

Frequent Urinary Tract Infection (UTI) 0 1 2 3
Urinary frequency

Urinary frequency 0 1 2 3
Vaginal dryness

Vaginal dryness 0 1 2 3
Abnormal bleeding

Abnormal bleeding 0 1 2 3
Pelvic pain, pressure, fullness, or bloating

Pelvic pain, pressure, fullness, or bloating 0 1 2 3
Uncomfortable intercourse

Uncomfortable intercourse 0 1 2 3
Loss of sexual feeling/desire

Loss of sexual feeling/desire 0 1 2 3
Loss of arousability & capacity for orgasm

Loss of arousability & capacity for orgasm 0 1 2 3
Loss of vitality

Loss of vitality 0 1 2 3
Nipple sensitivity

Nipple sensitivity 0 1 2 3
Discharge or leaking from nipples

Discharge or leaking from nipples 0 1 2 3
Breast tenderness

Breast tenderness 0 1 2 3
Loss of pubic hair

Loss of pubic hair 0 1 2 3
Swelling of hands, ankles, or breasts

Swelling of hands, ankles, or breasts 0 1 2 3
Heart palpitations

Heart palpitations 0 1 2 3
Shortness of breath

Shortness of breath 0 1 2 3
Food /sweets /salt cravings

Food /sweets /salt cravings 0 1 2 3
Increased appetite/weight gain

Increased appetite/weight gain 0 1 2 3
Visual disturbance or decreased vision

Visual disturbance or decreased vision 0 1 2 3
Difficulty hearing

Difficulty hearing 0 1 2 3
Diminished sense of taste

Diminished sense of taste 0 1 2 3
Diminished sense of smell

Diminished sense of smell 0 1 2 3

Women's Consultation Form

Women's Consultation Form

Have you had any of the following surgeries?

Have you ever used any of the following birth control methods: