Health Assesment
For Women
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Symptom
(select one option for each symptom)
Fatigue
Never
Mild
Moderate
Severe
Memory Loss
Never
Mild
Moderate
Severe
Mental confusion
Never
Mild
Moder
Severe
Decreased sex drive/ libido
Never
Mild
Moderate
Severe
Sleep Problems
Never
Mild
Moderate
Severe
Mood changes/ irritability
Never
Mild
Moderate
Severe
Tension
Never
Mild
Moderate
Severe
Migraine/severe headaches
Never
Mild
Moderate
Severe
Difficult to climax sexually
Never
Mild
Moderate
Severe
Bloating
Never
Mild
Moderate
Severe
Back
Next
Weight Gain
Never
Mild
Moderate
Severe
Breast tenderness
Never
Mild
Moderate
Severe
Vaginal Dryness
Never
Mild
Moderate
Severe
Hot Flashes
Never
Mild
Moderate
Severe
Night sweats
Never
Mild
Moderate
Severe
Dry and wrinkled skin
Never
Mild
Moderate
Severe
Hair is falling out
Never
Mild
Moderate
Severe
Cold all the time
Never
Mild
Moderate
Severe
Swelling all over the body
Never
Mild
Moderate
Severe
Joint Pain
Never
Mild
Moderate
Severe
Family History/ Activity Level
Heart Disease?
Yes
No
Diabetes
Yes
No
Osteoporosis
Yes
No
Alzheimer's Disease
Yes
No
Breast Cancer
Yes
No
Birth Control Method
None
Birth Control Pill
Abstinence
IUD- Mirena
IUD- Other
Menopause
Tubal Ligation
Hysterectomy
Other
Submit
Should be Empty: