Female Confidential Evaluation Form

Personal Information
Name:
Email:
Date of Birth:
Address:
Gender:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Physician Information
Physician Name:
Physician Phone:
Physician Address:
State:
City:
Zip Code:
Health Information
Height:
Weight:
Do you use tobacco?
Do you use alcohol?
Do you drink more than 2 caffeinated beverages per day?
Please check all that apply to you:


Other:
Please list all of the prescription medication that you are currently taking along with the strength,
date started, and how often.
Please list all of the over-the-counter medication that you currently or occasionally take.
Please check any nutritional/natural supplements that you currently or occasionally take.

Other:
Allergies: Please check all that apply.



Other:
Family History: Please check all that apply.
Family Members:
Family Members:
Family Members:
Family Members:
Family Members:
Family Members:





Have you had any of the following tests performed?
Mammogram:
Date of Last Test:
PAP Smear:
Date of Last Test:
Bone Density:
Date of Last Test:
How many pregnancies have you had?
How many children do you have?
Have you had any interrupted pregnancies?
Date:
Have you had a hysterectomy?
Date:
Have your ovaries been removed?
Date:
Have you had a tubule ligation
(tubes tied)?
Date:
When was your last period?
How long did it last?
Describe your last period:
Have you ever had what YOU would consider to be abnormal cycles?
If you answered YES, please explain your symptoms.
Do you have, or did you ever have Premenstrual Syndrome (PMS)?
If you answered YES, please explain your symptoms.
Please list any hormones that you have previously taken, the date started, the date stopped, and the reason for taking them.
Please check all of the hormonal symptoms that apply to you.







How do you currently feel?
How do you normally feel?
Even after sufficient sleep, do you have difficulty waking up or feel tired in the morning?
Do you start feeling more tired in the afternoons between 3:00 P.M and 5:00 P.M.?
Do you have more energy during the early evening hours?
Do you have difficulty falling asleep or staying asleep even when you feel fatigued?
Do you have cravings for sugar or salt more often than you used to?
Are you having trouble losing weight, especially around the waist?
Are you experiencing any feelings of depression?
Are you experiencing hair loss?
Do you have an increased need for caffeine or other stimulants?
Are you having trouble concentrating?
Are you experiencing recurring respiratory infections?
Does it take you longer than normal to recover from illness?
Do you have difficulty handling stress?
Are you experiencing a decrease in sex drive?
In the past year, have you dealt with a greater than normal amount of emotional stress?
Please check all of the symptoms of hypothyroidism that apply to you:




Food Journal
Please list everything eaten each day for the next 7-14 days. Include all drinks (tea, soda, water, etc.) and quantities (i.e. 1 can, 16 oz., etc.). Approximate times of meals and snacks will be helpful in evaluating dietary habits.
DAY 1
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
DAY 2
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
DAY 3
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
DAY 4
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
DAY 5
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
DAY 6
BREAKFAST:
LUNCH:
DINNER:
SNACKS:
DAY 7
BREAKFAST:
LUNCH:
DINNER:
SNACKS: