EmailMe Form - FEMALE HEALTH HISTORY FORM

Name

First Last

Date

MM / DD / YYYY

Email

SS #

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Cell

### - ### - ####

DOB

MM / DD / YYYY

SECTION 2: MEDICAL INFORMATION

UPLOAD LABS
(FILE UPLOAD)

***USE THIS TO UPLOAD LABS OR ANY IMPORTANT INFO***

PRIMARY CARE
PHYSICIAN

PHYSICIAN
PHONE

### - ### - ####

DATE OF LAST
PHYSICAL EXAM

MM / DD / YYYY

HEIGHT

FEET/INCHES

BODY WEIGHT

Wt (Lbs.)

SMOKER

YES..

NO..

CIGARETTES
PER DAY

ALCOHOL

YES..

NO..

NUMBER OF DRINKS
PER WEEK

ALLERGIES & DRUG
ALLERGIES

CURRENT MEDICATIONS
Include name, strength
and how often you take
your medication.

NAME-----------------STRENGTH-----------DOSE PER DAY

CURRENT SUPPLEMENTS
Include name, strength
and how often you take
your medication.

NAME-----------------STRENGTH-----------DOSE PER DAY

SURGICAL HISTORY
(include YEAR, TYPE OF PROCEDURE)

YEAR.......................................TYPE OF PROCEDURE............

PERSONAL HISTORY

TYPE OF CANCER

SECTION 3: FAMILY HISTORY

CHECK ALL THAT APPLY TO IMMEDIATE FAMILY MEMBERS

FAMILY HISTORY

TYPE OF CANCER

*FOR WOMEN ONLY****

HYSTERECTOMY

**YES**

**NO**

IF YES....

PARTIAL (UTERUS ONLY)

FULL

DATE OF HYSTERECTOMY

MM / DD / YYYY

REASON FOR HYSTERECTOMY

DATE OF LAST
MENSTRUAL CYCLE

TUBAL LIGATION

**YES**

NO**

ARE YOU CURRENTLY PREGNANT

**YES**

**NO**

HOW MANY TIMES HAVE
YOU BEEN PREGNANT

GIVEN BIRTH?

HAVE YOU EVER BEEN
TREATED FOR INFERTILITY

**YES**

**NO**

DO YOU HAVE A HISTORY
OF OVARIAN CYSTS ?

**YES**

**NO**

DATE OF LAST
MAMMOGRAM

MM / DD / YYYY

ABNORMAL

**YES**

**NO**

IF ABNORMAL PLEASE
EXPLAIN

DATE OF LAST PAP SMEAR

MM / DD / YYYY

ABNORMAL

**YES**

**NO**

IF YES, PLEASE EXPLAIN

BIRTH CONTROL

**YES**

**NO**

TYPE

HAVE YOU EVER BEEN TREATED FOR INFERTILITY

**YES**

**NO**

IF YES, PLEASE EXPLAIN

**SYMPTOM CHART WOMEN*

**********************ESTROGEN DEFICIENT SYMPTOMS*******************

HOT FLASHES

NIGHT SWEATS

BLOATING/WATER
RETENTION

WEIGHT GAIN

MOOD SWINGS

HEAVY MENSES/
CRAMPING

SYMPTOMS-WOMEN

*******************PROGESTERONE DEFICIENT SYMPTOMS*****************

INSOMNIA

MOOD SWINGS

MIGRAINES

ANXIETY/
DEPRESSION

LOW LIBIDO

LOSS OF MUSCLE
TONE

POOR EXERCISE
RECOVERY

DIFFICUlTY REACHNG
ORGASM

LACK OF DRIVE/
MOTIVATION

This signature implies
that the aforementioned
infrmation is true and accurate to the best of my ability.

Clear

*****************SECTION 2: MEDICAL INFORMATION*****************

SECTION 3: FAMILY HISTORY

***********************FOR WOMEN ONLY**************************

**********************SYMPTOM CHART WOMEN*********************

************************SYMPTOMS-WOMEN************************

SECTION 2: MEDICAL INFORMATION

*FOR WOMEN ONLY****

**SYMPTOM CHART WOMEN*

SYMPTOMS-WOMEN