Women’s Health History and Intake Form Women's Health History and Intake Form 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 ContactsEmergency Contact's Full Name* Emergency Contact's Phone*Primary Physician's Full Name* Primary Physician's Phone*All About YouDate of Birth* Month Day Year 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 HistoryNext to each illness/condition that you have experienced, enter details and specific datesCancer Diabetes Hepatitis High Blood Pressure Heart Disease Rheumatic Fever/Childhood Diseases Thyroid Disease Other... SurgeriesSignificant Trauma (Auto Accidents, Falls, etc.)Allergies (Drugs, Metal/Chemicals, Foods)Medicines Taken in the Last Three Months (Vitamins, Drugs, Herbs)Personal InformationDo you exercise regularly? If Yes, please describeHave you ever been on a restricted diet? If Yes, what kind and why?Average Daily Diet - Please describe in detailMorningAfternoonEveningDo 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 monthsGeneral Fevers Sweat Easily Bleed or Bruise Easily Change in Appetite Poor Sleeping/Insomnia Chills Weight Loss/Gain Strong Thirst Fatigue Night Sweats Sudden Energy Drop Cravings If sudden energy drop, What time of day? If Cravings, for what? Skin and Hair Rashes Itching Change in Hair/Skin Texture Ulcerations Eczema Hives Loss of Hair Acne Recent Moles Other If Other, please explain. Head/Eyes/Ears/Nose/Throat Dizziness Glasses Poor/Blurry Vision Cataracts Eye Strain Eye Pain Eye Surgeries Color Blindness Floaters (Spots in Front of the Eyes) Night Blindness Tinnitus (Ringing in the Ears) Earaches Poor Hearing/Hearing Aids Headaches/Migraines Sinus Problems Teeth Grinding Concussions Nose Bleeds Jaw Clicks Recurrent Sore Throats Sores on Lips/Tongue Other If Eye Surgeries, What and When? If Headaches/Migraines, where located? If Other, please explain. Cardiovascular High Blood Pressure Low Blood Pressure Irregular Heartbeat Cold Hands/Feet History of Blood Clots Difficulty Breathing Swelling of Hands/Feet Phlebitis Chest Pain Fainting Other If Other, describe. Respiratory Cough Bronchitis Difficulty Breathing when Lying Down Asthma Production of Phlegm Coughing Blood Wheezing Pneumonia Pain with Deep Breath Other If Phlegm, what color? If Other, describe Gastrointestinal Nausea Vomiting Diarrhea Constipation Gas Belching Black Stools Blood in Stools Indigestion Bad Breath Rectal Pain Hemorrhoids Bleeding Gums Abdominal Pain/Cramps Chronic Laxative Use Other If Other, describe: Genitourinary Pain Upon Urination Frequent Urination Blood in Urine Urgency to Urinate Unable to Hold Urine Night Urination Kidney Stones Decrease in Flow Impotency/Infertility Sores on Genitals Other If Other, describe: If Night Urination, How many times? Gynecological HistoryCheck all that apply Infections Injuries to Genitalia Genital Surgeries Genital Cysts Genital Warts Herpes Sexually Transmitted Diseases Please list and enter date(s)MenstruationAge 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) Dilute/Pale Red Bright Red Dark Red Purple Brown Black 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 ClotsDo 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? Quarter Dime Nickel Very Small Golf Ball What color do the clots tend to be? Vaginal DischargesDo 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 applyDo they cause Vaginal Itching? No Yes Sometimes What alleviates the itching? Describe the consistency of the discharges Pain During MensesDo 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 ManifestationsWhat signs and symptoms do you experience throughout your menstrual cycle? Abdominal Pain Low Back Discomfort Cramps in low abdomen area Headaches/Migraines Sore/Tight Muscles Poor Memory Changes in Urination Dizziness Dry Eyes Floaters Changes in Body Temp Changes in Sexual Desire Breast Tenderness Tiredness Irritability Mood Swings Weepiness Night Sweats Sleep Disturbance Water Retention Vaginal Discharges Difficulty Breathing Clumsiness Other Check all that apply.If Other, explain below: ReproductiveAre you currently pregnant? No Yes Is it possible that you could be pregnant? No Yes Number of PregnanciesNumber of AbortionsNumber of MiscarriagesHow many months into the pregnancy/ies was/were the miscarriages?Number of Premature BirthsWas labor abnormal or complicated in any way?Number of vaginal deliveriesNumber of cesaerian sectionsDo 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 PillHave 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: MusculoskeletalPlease check areas where you experience pain Neck Back/Spine Hand/Wrist Shoulder Elbow Knee Ankle Hips Muscle Weakness Numbness Parathesias (Tingling) Other If Other, describe: NeuropsychologicalCheck all that you experience. Seizures Dizziness Loss of Balance Lack of Coordination Poor Memory Concussion Depression Anxiety Bad Temper Easily Susceptible to Stress Been treated for emotional challenges? No Yes Have you ever considered or attempted suicide? No Yes Any other neuropsychological issues? EmailThis field is for validation purposes and should be left unchanged.
