Women’s Health History and Intake Form Marlborough Wellness Center

LAST Name*

FIRST Name*

Street Address*

City/Town*

State*

Zip Code*

Home Phone*

Day Phone*

Your Email*

Occupation

How did you hear about MWC?

Your Medical Contacts

Emergency Contact's Full Name*

Emergency Contact's Phone*

Primary Physician's Full Name*

Primary Physician's Phone*

All About You

Date of Birth*

MM

DD

YYYY

Your Age*

Have you been treated by Acupunture or Oriental Medicine before?*

No
Yes

Main concern(s) you would like us to address*

When did this begin?

How does it interfer with your daily activities (ie: work, sleep, sex)?

Have you been given a formal diagnosis for this problem?

No
Yes

What other treatments have you tried?

Family Medical History

Diabetes
Cancer
High Blood Pressure
Heart Disease
Stroke
Seizures
Asthma
Allergies
Other

Check all that apply.

if Other, describe.

Your Past Medical History

Next to each illness/condition that you have experienced, enter details and specific dates

Cancer

Diabetes

Hepatitis

High Blood Pressure

Heart Disease

Rheumatic Fever/Childhood Diseases

Thyroid Disease

Other...

Surgeries

Significant Trauma (Auto Accidents, Falls, etc.)

Allergies (Drugs, Metal/Chemicals, Foods)

Medicines Taken in the Last Three Months (Vitamins, Drugs, Herbs)

Personal Information

Do you exercise regularly? If Yes, please describe

Have you ever been on a restricted diet? If Yes, what kind and why?

Average Daily Diet - Please describe in detail

Morning

Afternoon

Evening

Do you currently smoke?

No
Yes

Yes: How much do you smoke per day?

NO: Have you ever smoked, and, if so, how much per day and when did you quit?

Please describe any use of drugs for non-medical purposes.

How many caffeinated beverages do you drink per day?

How much water do you drink per day?

How much alcohol do you drink per day?

Are there any other concerns you would like us to address?

In all the areas listed below, please check if you have experienced any symptoms in the past 3 months

General

If sudden energy drop, What time of day?

If Cravings, for what?

Skin and Hair

If Other, please explain.

Head/Eyes/Ears/Nose/Throat

If Eye Surgeries, What and When?

If Headaches/Migraines, where located?

If Other, please explain.

Cardiovascular

If Other, describe.

Respiratory

If Phlegm, what color?

If Other, describe

Gastrointestinal

If Other, describe:

Genitourinary

If Other, describe:

If Night Urination, How many times?

Gynecological History

Check all that apply

Infections
Injuries to Genitalia
Genital Surgeries
Genital Cysts
Genital Warts
Herpes

Sexually Transmitted Diseases

Please list and enter date(s)

Menstruation

Age at onset:

Is your menstrual cycle on a regular schedule?

No
Yes

Was your menstrual cycle ever regular?

No
Yes

YES: If yes, when?

Which is most true about your menstrual cycle?

Tends to be Late
Tends to be Early
Alternates between Late and Early
Tends to be Just Right

Do you have Spotting in between Periods?

No
Yes

How many days does your period last?

Color of Menstrual Blood (on average)

Consistency of Menstrual Blood (on average)

Thin/Dilute
Thick
Mucous-Like
Moderate/Normal

Is there Mucous in your Menstrual Blood Flow?

No
Yes

Is there a Specific Smell to your Menstrual Blood? Please explain:

Presence of Clots

Do you experience Blood Clots in your Menstrual Cycle Flow?

No
Yes

In general, how many clots would you say you get during a menstrual cycle?

A few
Many

What size are the clots?

What color do the clots tend to be?

Vaginal Discharges

Do you have Vaginal Discharges?

No
Yes

YES: Primarily when and how much?

Is there an odor?

Leathery
Fishy
Other

Other: Describe the odor

What is the color?

Clear
White
Yellow
Green
Blood Tinged

Check all that apply

Do they cause Vaginal Itching?

No
Yes
Sometimes

What alleviates the itching?

Describe the consistency of the discharges

Pain During Menses

Do you experience pain during menses?

No
Yes

When do you experience the pain?

Before
During
After

Check all that apply.

Location of the pain?

Upper Abdomen/Under Ribcage
Lower Abdomen
Low Back

Check all that apply.

What is the nature of the pain?

Sharp
Dull
Both

Does the pain lessen/alleviate by...?

Heat
Cold
Massage
Rest
Activity

Check all that apply.

Clinical Manifestations

What signs and symptoms do you experience throughout your menstrual cycle?

Check all that apply.

If Other, explain below:

Reproductive

Are you currently pregnant?

No
Yes

Is it possible that you could be pregnant?

No
Yes

Number of Pregnancies

Number of Abortions

Number of Miscarriages

How many months into the pregnancy/ies was/were the miscarriages?

Number of Premature Births

Was labor abnormal or complicated in any way?

Number of vaginal deliveries

Number of cesaerian sections

Do you have a history of breast feeding?

No
Yes

Did you have any difficulties with lactation?

No
Yes

Describe the difficulties:

Do you have a history of infertility?

No
Yes

Infertility: What thereapies/treatments did you utilize?

Oral Contraception/Birth Control Pill

Have you ever taken oral contraception (birth control pill)?

No
Yes

Pill: For how long?

Pill: When did you start?

Are you currently using oral contraception?

No
Yes

When did you stop taking the birth control?

Did you notice any changes in your menstrual cycle when you did stop taking the oral contraception?

No
Yes

Describe the changes:

Musculoskeletal

Please check areas where you experience pain

If Other, describe:

Neuropsychological

Check all that you experience.

Been treated for emotional challenges?

No
Yes

Have you ever considered or attempted suicide?

No
Yes

Any other neuropsychological issues?

Email

This field is for validation purposes and should be left unchanged.

Marlborough Wellness Center

Women’s Health History and Intake Form

Women's Intake

Your Medical Contacts

All About You

Your Past Medical History

Personal Information

Average Daily Diet - Please describe in detail

In all the areas listed below, please check if you have experienced any symptoms in the past 3 months

Gynecological History

Menstruation

Presence of Clots

Vaginal Discharges

Pain During Menses

Clinical Manifestations

Reproductive

Oral Contraception/Birth Control Pill

Musculoskeletal

Neuropsychological

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