Date of Birth:


City/Town:                                                      State:                            Postcode:

Tel number:                                                                                 Mobile:

Email Address:

Height:                                          Weight:

Your Doctor’s Name:


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





Mood Swings:



Hot Flushes/Night Sweats:


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

  1. Hello, this is a question regarding hashimotos. I tried writing to your email address but the address would not be “recognized”. I could not find an article addressing armour thyroid med vs Synthroid for Hashimoto’s patients. Long ago I was advised to not take armour and stay with Synthroid and Levothyronine dosage due to Hashimoto’s. Is there an article or an opinion you have regarding this? Thank you, Sincerely, Sandi Lane

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