Women’s Health History and Intake Form Marlborough Wellness Center

Women's Intake

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*
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 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
- 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 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)
- 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 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?
- Quarter
- Dime
- Nickel
- Very Small
- Golf Ball
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?
- 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:
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
- Neck
- Back/Spine
- Hand/Wrist
- Shoulder
- Elbow
- Knee
- Ankle
- Hips
- Muscle Weakness
- Numbness
- Parathesias (Tingling)
- Other
If Other, describe:
Neuropsychological
Check 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?
Phone
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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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