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1333540640HORMONE BALANCE QUESTIONNAIRE FOR WOMENName:Date:Address:City:State:Zip:Home Phone:Cell Phone:Work Phone:Date of Birth:Age:Height:Weight:Primary Care Doctor:Email:HEALTH HISTORYDo you have a personal or family history of any of the following?Uterine CancerNoYes (relationship)_________________________________Ovarian CancerNoYes (relationship)_________________________________Breast CancerNoYes (relationship)_________________________________Fibrocystic BreastNoYes (relationship)_________________________________OsteoporosisNoYes (relationship)_________________________________Polycystic Ovarian SyndromeNoYes (relationship)_________________________________Have you had any of the following tests?MammogramNoYes (Date)_____________Abnormal?NoYesPAP SmearNoYes (Date)_____________Abnormal?NoYesDEXA ScanNoYes (Date)_____________Abnormal?NoYesSince you began having periods, have you had what you consider to be abnormal cycles? No YesIf ‘YES’, please explain _________________________________________________________________________________________________________________________________________page 100B i o g e n i c s M DHORMONE BALANCE QUESTIONNAIRE FOR WOMENWhen was your last period? ____________________________________________________________How many days did it last? _____________________________________________________________Did/Do you have Premenstrual Syndrome (PMS)? No Yes (Specify symptoms experienced) ____________________________________________________________________________________________________________MEDICAL CONDITIONS / DISEASES (please check all that apply)Heart Disease (heart attack, CHF, etc.)Blood Clotting ProblemsHigh CholesterolDiabetesHigh Blood PressureArthritis or Joint ProblemsCancer (type ___________)DepressionUlcers (stomach, esophagus)Epilepsy or Seizure DisorderThyroid ProblemsHeadaches / MigrainesHormone Related IssuesEye Disease (glaucoma, etc.)Lung Problems (asthma, COPD, etc.)Liver or Gastrointestinal DisorderOther (please explain)PREVIOUS SURGERIES / HOSPITALIZATIONS (please list)How many pregnancies have you had? ________________ How many children? ____________Have you had a hysterectomy?NoYes (date of surgery)_______________________Have you had your ovaries removed?NoYes (date of surgery)_______________________Have you had your tubes tiedNoYes (date of surgery)_______________________Please list any other surgeries you have had:___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ___________________________________________page 200B i o g e n i c s M DHORMONE BALANCE QUESTIONNAIRE FOR WOMENLIFESTYLEDo you smoke?YesNo (details) __________________________________________Do you drink alcoholYesNo (details) __________________________________________Do you use recreational drugs?YesNo (details) __________________________________________Do you exercise?YesNo (details) __________________________________________ALLERGIES / MEDICATION INTOLERANCES (please list)I have no allergies or medication intolerances that I know ofMEDICATIONSCurrent Prescription and Over-the-Counter Medications___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ___________________________________________List Hormones Currently or Previously Taken___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ___________________________________________Are you currently using or have you previously used Birth Control Pills, Mirena, NuvaRing, Depo-Provera Shots or any other type of contraception? Yes No (details) _______________________________________Any problems? Yes No (details, if ‘Yes’) _______________________________________________________________________________________________________________________________________________________page 300B i o g e n i c s M DHORMONE BALANCE QUESTIONNAIRE FOR WOMENNUTRITIONAL SUPPLEMENTSPlease circle the product you are using:Vitamins ( multiple or single vitamins such as B complex, E, C, D, beta carotene, other) Minerals (calcium, magnesium, chromium, iron, zinc, coper, other) Herbs (ginseng, gingko biloba, echinacea, medicinal teas, other) Enzymes (Digestive, papaya, bromelain, CoQ10, other) Nutritional/Protein Supplements (shark cartilage, protein powders, amino acids, fish/flaxseed oil, other) Other (please list)I do not take any nutritional supplementsCURRENT SYMPTOMSFor each item identified below, circle the number that best fits the symptoms you are experiencing0 = none ? 1 = mild ? 2 = moderate ? 3 = severeItemItemHot Flashes0123Fibrocystic Breast0123Night Sweats0123History of Fertility Problems0123Difficulty Falling Asleep0123Cervical Dysplasia0123Difficulty Staying Asleep0123Cyclical Headaches0123Morning Fatigue0123Urinary Tract Infections0123Evening Fatigue0123Urinary Incontinence0123Vaginal Dryness0123Constipation0123Painful Intercourse0123Bone Loss0123Loss of Sex Drive0123Joint Aches and Pains0123Breast Tenderness0123Fibromyalgia0123page 4470535-35560Biogenics MDHORMONE BALANCE QUESTIONNAIRE FOR WOMENItemItemDepression0123Thinning Skin0123Anxiety0123Oily Skin0123Irritable0123Weight Gain - Hips0123Memory Lapses0123Weight Gain - Waist0123Tearfulness0123Decreased Muscle Mass0123Foggy Thinking0123Sugar / Carb Cravings0123Stress0123Unusual Sweating0123Hair Loss on Scalp0123Hoarseness0123Increased Facial or Body Hair0123Bulging Eyes0123Dry / Brittle Hair0123Slowed Reflexes0123Dry / Brittle Nails0123Cold Body Temperature0123Acne0123Blood Pressure Problems0123What are your goals with Bioidentical Hormone Replacement Therapy (BHRT)?Please write down any questions you have about BHRT:___________________________________________ __________________________Patient SignatureDate ................
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