Female
Name:
Date of Birth:
Address:
City/Town: State: Postcode:
Tel number: Mobile:
Email Address:
Height: Weight:
Your Doctor’s Name:
Address;
Do you Smoke: How often and How much:
Did you ever smoke: When did you give up:
Do you drink Alcohol: How often and How much:
Do you have any allergies:
Marital Status: No. of Pregnancies: No. Miscarriages:
What Work do you do:
What operations have you had:
Medical conditions:
What medicines are you on:
Family history: Any important illness/diseases in the family:
When last did you have: Mammogram: Pap Test: BP check:
Hormones previously taken:
Date of last period:
Menopause Rating scale.(Use in preference to one below)
Hormone Symptom Chart: None Mild Moderate Severe
Anxiety:
Depressed:
Forgetful:
Headaches:
Mood Swings:
Irritable:
Emotional:
Hot Flushes/Night Sweats:
Fatigue/Tiredness:
Insomnia/Sleep disturbance:
Sore Joints:
Urine leaks when straining:
Loss of Sex Drive:
Painful sexual intercourse:
Loss of enjoyment in Sex: If Yes, then please do the Decreased_Sexual_Desire_Screener_DSDS_Female_Sexual_Dysfunction_Tool
Fluid Retention:
Breast pain/Tenderness:
Hair loss:
Weight Gain:
Excess facial/body hair:
Skin Crawling/Itchy:
Please Print and bring with you when you see Dr Holloway
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