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