Women's Health Intake Form For women seeking help with gynecological or hormonal conditions First Name Last Name Email Mobile Phone Birth Date Gender Female Male Relationship Status Single Married Divorced Widowed Occupation Height Weight Have you had acupuncture before No Yes How did you hear about us? Friend/Relative Doctor Google Facebook Lecture Other Name of doctor or friend that referred you Describe what you would like us to help you with How long have you had this problem? What types of treatment have you or are you receiving for it? Recently the condition has: Not Changed Worsened Improved What makes it worse? What makes it better? List medications, supplements you're taking (or enter "none" if none) List any major injuries, accidents, or surgeries and when they took place (or enter "none" if none) Anything else you think we should know about the problem you are seeking help with Check all in your FAMILY HIstory Arthritis Anxiety Asthma Autoimmune Disease Bowel issues Cancer Chronic skin conditions Depression Diabetes Dementia Hypertension Heart Attack Stroke Liver Disease Kidney Diseas Ulcer Osteoporosis/Ostopenia STP HIV/AIDS Infertility Check all in YOUR history Arthritis Anxiety Asthma Autoimmune Disease Bowel issues Cancer Chronic skin conditions Depression Diabetes Dementia Hypertension Heart Attack Stroke Liver Disease Kidney Diseas Ulcer Osteoporosis/Ostopenia STP HIV/AIDS Infertility List known food or drug allergies (or enter "none" if none): Energy level is generally Very low Low Normal High Very high Check all that apply Energy fluctuates a lot during the day Frequent sleepiness after meals Sudden burst of Energy in the evening Very tired in the moring Mood is generally Sad Irritable/angry I'm pretty chill Excited/upbeat Worried Anxious/nervous Any mood issues (check all that apply) Anger control issues Anxiety Bipolar Depression Panic attacks Weight Stable Recent Gain Recent loss Body temp sensation often feel warm/hot Often feel cold/chilled Fluctuates Stable/Normal Check all that apply Cold hands and feet Frequent sweating Hot flashes Night sweats Warm Hands and feet Bowel Habits 1-3x daily More than 1-3x daily 3-5x per week Less than 3x per week Check all that apply for digestion/bowel movement Acid reflux Bloating/gas Celiac/gluten sensitivity Constipation Cramping/urgency Fullness after meals Hemorrhoids IBS Indigestion Loose stool Sleep is: Terrible Not great Pretty good Awesome Check all that apply to sleep: Difficult to fall asleep Difficult to stay asleep Difficult to wake up Restless sleep Nightmares Wake up and difficult to fall back asleep Wake up earlier than desired Wake up to urinate multiple times Bedtime Wake time Number of times you wake during the night Check all that apply: Allergy/sinus issues Carbohydrate cravings Concussion Chronic cough Dizziness/lightheadedness Ear/hearing problems Eye problems Fainting Frequent colds/flu Frequent headaches/migraines Heart palpitations/irregular heartbeat Joint/spinal problems Low blood pressure Loss of taste/smell Muscle weakness/soreness Nails soft or break easily Shortness of breath Swelling in legs or feet Age of onset of menstruation Age of onset of menopause (if applicable) Date last period started Cycle length (e.g. 28 days, 27-35 days) Length of period flow (e.g. 4 days, 5-7 days) Cramping None Mild Moderate Severe Color of flow Normal red Dark Red Pale red Black Other Flow amount is Normal Light Heavy Extremely light Extremely Heavy Check all that apply: Lots of clots Lots of tissue Mid-cycle Bleeding/spotting Spotting prior to period Spotting more than 2 days after end of period Tired during/after period Severe mood swings before or during period Do you ovulate regularly Yes No Not sure Cervical mucus with ovulation is Normal Scanty Excessive Absent Not sure/don't check If you track ovulation - how? (check all that apply) Basal body temp (BBT) Ovulation predictor kit App on my phone Don't track Other Anything else you want us to know about your cycles / period / ovulation Describe time and types of foods you eat for breakfast (e.g. eggs, oatmeal, 7am) Describe time and types of foods you eat for lunch: (e.g. salad, sandwich, 12 noon) Describe time and types of foods you eat for supper (e.g. chicken, rice, vegetables 7 pm) Describe time and types of snacks you eat: Submit
