FEMALE HEALTH ASSESSMENT

Please take the time to answer this questionnaire, only your doctor will review this. Leave questions blank if you are uncomfortable to answer or would like to discuss it further with Dr. Samra-Latif.

Personal Profile

Name / Home Phone / Date
Street Address / Work Phone / Date of Birth/Age
City, State, Zip / Marital Status
□ Single □ Married
□ Divorced □ Separated
□ Widowed / How did you find out about us? □ Newspaper
□ Google/Web
□ Friend/Family
Occupation / Education / Spouse/Partner’s Name
Emergency Contact/Relationship / Home Phone / Work Phone
What brings you to the office today?
□ Annual Exam/Routine Care
□ Problem/Issue (Please describe briefly)
□ I was referred by
Past Hospitalizations and Surgery:
Current Medications / Allergies to Medications:
Has anyone in your family suffered from: (Indicate relationship)
□ Diabetes / □ Heart Disease / □ Drinking Problem / □ Ovarian Cancer
□ Stroke / □ High Blood Pressure / □ Breast Cancer / □ Colon Cancer
□Blood clots in legs/lungs / □Osteoporosis / □Birth Defects / □Depression
□Alcohol Dependency / □Drug Dependency / □Mental Illness / □Uterine cancer
□Thyroid Disease / □High Cholesterol / □Bleeding Disorder
Mother
□ Alive □ Deceased / Father
□ Alive □ Deceased / # Siblings
Social History / Gynecologic History

Yes No

/

Describe

/ Last Menstrual Period: /

Frequency

Duration:

Age at Onset:

□ □

/

Smoking

/ Last Pap Smear: / Normal?

□ □

/

Alcohol

/ Last Mammogram: / Normal?

□ □

/

Illegal Drugs

/ Last DEXA: / Normal?

□ □

/

Seat Belt Use

/ Last Colonoscopy: Normal?

□ □

/

Vitamin Supplementation

/ Are you Presently Sexually Active? □Yes □ No

□ □

/

Calcium Intake

/ Ever Been Sexually Active? □ Yes □ No

□ □

/

Exercise Regularly

/ Sexual Partners are □ Men □ Women □ Both

□ □

/

Do you Feel Threatened at Home

/ Current Method of Contraception:

□ □

/

Have you Ever Been Sexually or Physically Abused?

/ Have you had HIV testing? □Yes □No

Obstetric History

Number / Number / Number
Pregnancy / Abortions / Miscarriages
Living Children / Vaginal Deliveries / Cesarean Sections
Any Pregnancy Complications?
□ Hypertension □ Diabetes □ Blood Clot □ Hemorrhage □ Depression

Supplement Use and Reason for Use

Have you had any of the following?

Yes / No / Yes / No
Asthma / Pneumonia/Lung Disease
Tuberculosis / Kidney Disease
Bleeding Disorder / Heart Disease
Hypertension / Diabetes
Abnormal Pap / Infertility
Stroke / Eating Disorder
Depression / Other Mental Illness
Hepatitis / Arthritis
Bowel Problems / Gallbladder Disease
Back Problems / Headache
Broken Bones / Thyroid Disease
Anemia / Cancer
Weight Loss / Weight Gain
Easy Bruising / Sexually Transmitted Disease
Liver Disease / Blood Transfusion
Genetic Defect / Birth Defect
Are You Experiencing Any of the Following Symptoms?

General

□ Weight Loss or Gain
□ Fevers
□ Trouble Sleeping
□ Chronic Fatigue
□ Excessive Bleeding
□ Easy Bruising
□ Abnormal Thirst
□ Difficulty Sleeping?
□ Hair loss
□ Cold Intolerance /
Lungs
□ Coughing Up Blood
□ Shortness of Breath
□ Chronic Cough
□ Blood Clot in the Lungs
□ Painful Breathing
□ Wheezing /
Musculoskeletal
□ Muscle Weakness
□ Joint Pains
□ Joint Swelling
□ Clot in Leg Vein /
Menstrual Problems
□ Cramps/Pain
□ Heavy Bleeding
□ Too Frequent Periods
□ Bleeding Between Periods
□ Missed a Period
□ Other Period Issue
□ Painful Periods / Other Gynecologic Issues
□ Vaginal Discharge
□ Itching/Irritation
□ Vulvar Pain
□ Vulvar lump/growth
□ Vulvar Sores
Neurologic
□ Frequent/Severe Headaches
□ Dizziness
□ Seizures
□ Numbness
□ Trouble Walking
□ Fainting Spells
Sexual Problems
□ Painful Intercourse
□ Bleeding after Intercourse
□ Decreased Desire
□ Orgasm Problems
□ Dryness
□ Possible Exposure to STD
□ Other Sexual Issue
Cardiovascular
□ Chest Pain
□ Irregular Heart Beat
□ Ankle/Hand Swelling /
Pre Menstrual Problems
□ Bloating/Swelling
□ Mood Changes
□ Breast Changes
□ Headaches
□ Acne
□ Other PMS Issue
Eyes
□ Itchy, Red Eyes
□ Vision Problems
Ears
□ Ear Pain
□ Ringing in Ears
□ Hearing Loss /
Gastrointestinal
□ Frequent Diarrhea
□ Constipation
□ Bloody Stools
□ Nausea/Vomiting
□ Hemorrhoids
Skin
□ Acne
□ Unwanted Hair Growth
□ Unusual Lump or Growth
□ Dry Skin
Menopause Issues
□ Hot Flashes
□ Night Sweats / Would you like to discuss any of the following?
□ Contraception
□ Menopause Issues
□Fertility Issues
□ Self Breast Exam
□ Sexuality Issues
□ STD’s
□ Other
Nose
□ Sinus Problems
□ Nose Bleeds
Urinary
□ Incomplete Urination
□ Loss of Urine
□ Painful Urination
□ Bloody Urine
□Urine Loss with Cough/Exercise /
Emotional
□ Excessive Worry
□ Depression
□ Frequent Crying
□Serious thoughts of harming yourself or others /

Breast Problems

□ Breast Pain
□ Breast Lump
□ Nipple Discharge
□ Other Breast Issue

Mouth

□ Sore Throat
□ Mouth Sores
□ Dental Problems

SYMPTOM CHECKLIST

Instructions: Please note the symptoms in the list that you experience on a regular basis. Place an “X” in the column corresponding the frequency and severity of each symptom. If you rarely have the symptom, just leave that line blank.

Symptom FrequencySymptom Severity

1=A Few days a Month1=Mildly Noticeable

2=A Few days a Week 2=More Bothersome

3=Almost Every Day 3=Severe/Debilitating

SYMPTOM / 1 / 2 / 3 / 1 / 2 / 3
Aches & Pains
Fatigue (All-Day)
Fatigue (Morning)
Fatigue (Afternoon)
Fatigue (Evening)
Irritability/Mood swing
Mood Swings
Foggy Mind
Anxiety
Can’t Fall Asleep
Interrupted Sleep
Waking Up Unrefreshed
Carb. Cravings
Depression
Heavy Periods
Cyclic PMS Symptoms
Breakthrough Bleeding
Hot Flashes
Breast Tenderness
Headaches
Bloating
Night Sweats
Low Sex Drive
Weight Gain
Vaginal Dryness
Hair Loss
Dry,Thinning Skin
Cold Body Temperature

LIFESTYLE QUESTIONS

Do you smoke cigarettes?___ YES __ NO If so, how many cigarettes per day? ______

Do you drink alcohol? ___YES ___ NO If so, how many drinks per week? ______

Do you use any street drugs? _____ YES _____ NO (all answers are confidential)

How many caffeine-containing drinks do you have a day? ___ (coffee, tea, sodas, energy drinks)

What time do you go to bed at night? ______How long until you fall asleep? ______

How many times do you wake up a night? ____ Do you go to sleep with the TV on? ______

What do you do when you wake up at night? ______

What time do you wake up in the morning on a typical work day? ______

Do you take anything to help you fall asleep? ______

Do you eat after 8PM? _____ YES _____ NO Do you feel refreshed when you wake up? ______

Do you exercise for at least 30 minutes at a time, at least 3 days per week? ___ YES ___ NO

What do you do for exercise?______

What time of day do you usually exercise? ______

How many meals a day do you eat? _____ Do you snack between meals? ___YES __NO

Do you drink at least 64 ounces of water per day? ____YES _____ NO

What prescription diet pills have you taken in the past?______

What was your most successful diet? ______How much did you lose?______

How much weight would you realistically like to lose in the next year? ______pounds.

STRESS QUESTIONS Please circle all current stressors in your life.

MOVED YOUR HOMEJOB CHANGEJOB STRESS/LOSS

ILL FAMILY MEMBERSMARITAL PROBLEMSDIVORCE/SEPARATION

DEATH OF SPOUSE/CHILDFORECLOSURE/BANKRUPTCYLEGAL PROBLEMS

NEW MARRIAGERETIREMENTTROUBLE W/ IN-LAWS

PROBLEMS WITH CHILDRENNEW PERSON LIVING WITH YOU

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