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Female Patient Questionnaire & History
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Social
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Are you sexually active?
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Have you completed your family?
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Has your sex life suffered?
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Habits
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How many cigarettes or cigars do you smoke per day?
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How many e-cigarettes do you use per day?
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How many caffeine beverages do you drink per day?
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How many alcoholic beverages do you drink per week?
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Do you drink more than 10 alcoholic beverages a week?
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Medical Illnesses
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Select any of the following that you have or have had
• • •
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If you have or had cancer, enter the type and year?
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Female Health Assessment
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Which of the following symptoms apply to you currently (in the last 2 weeks)? Choose 0 for Never, 4 for Very Severe
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Symptoms
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Hot flashes
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Sweating (night sweats or increased episodes of sweating)
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Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
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Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
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Irritability (mood swings, feeling aggressive, angers easily)
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Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
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Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy)
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Sexual problems (change in sexual desire, sexual activity, orgasms and/or satisfaction)
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Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
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Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
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Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
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Difficulties with memory
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Problems with thinking, concentrating or reasoning
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Difficulty learning new things
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Trouble thinking of the right word to describe persons, places or things when speaking
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Increase in frequency or intensity of headaches or migraines
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Hair loss, thinning or change in texture of hair
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Feel cold all the time of have cold hands or feet
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Weight gain or difficulty losing weight despite diet and exercise
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Dry or wrinkled skin
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Total Score
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Severity based on Score
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