16622 North Dale Mabry Highway - Tampa, Florida

Phone:  (813) 265-8885

Fax:  (813) 265-8898

Personal Health Profile - Women

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Name:

Please list all medical problems you currently have and those you have had in the past:

Please list any injuries, accidents, surgeries or hospitalizations you have had:

When was your last pap smear?

Was it normal?

Yes

No

Have you ever had an abnormal pap smear?

Yes

No

  

Have you ever had an abnormal mammogram?

Yes

No

Are you still having periods?

Yes

No

When was your last period?

Are you allergic to any medicines?

Yes

No

If yes please list medicines you are allergic to:

Please list any medicines and supplements you are taking:

Social History:

Current marital status

Married

Single

Do you have children?

Yes

No

If so, what are their ages?

How many pregnancies and births have you had?

Were the births vaginal deliveries or C-sections?

Vaginal

C-section

Were there any complications with your pregnancies?

Yes

No

Do you smoke?

Yes

No

If so, how much and how often?

Do you drink alcohol?

Yes

No

If so, how much and how often?

       

Do you exercise?

Yes

No

If so, what do you do and how often?

If you work outside the home, what do you do?

Describe the level of stress you are experiencing in your life.  What do you do to help cope?

Briefly describe your diet on a typical day (be honest!!):

Please list any health problems of members of your immediate family (mother, father, brothers, sisters and children):

From the following list of problems, please check those that pertain to you:
Hot flashes Night sweats Vaginal dryness Incontinence  
Foggy thinking Memory lapses Shortness of breath Dizziness  
Indigestion Frequent colds Chest pain or pressure Tearful  
Depressed Heart palpitations Bone loss Disturbed Sleep  
Headaches Aches and pains Fibromyalgia Morning fatigue  
Evening fatigue Allergies Hoarseness Excess stress  
Sugar Craving Decreased libido Loss of scalp hair Acne  
Mood swings Tender breasts Bleeding changes Nervous  
Irritable Anxious Water retention Uterine fibroids  
Rapid aging High cholesterol Slow pulse rate Hair dry or brittle  
Thinning skin Constipation Rapid heartbeat Infertility problems  
Hearing loss Goiter Swelling or puffy eyes or face  

Cold body temperature

 Elevated Triglycerides Fibrocystic breasts
Weight gain in the waist Increased facial or body hair Decreased sweating
Weight gain in the hips Nails breaking or brittle Decreased muscle size
Decreased stamina Sensitivity to chemicals  
 
Other (please specify):  
 

 
 

 

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