Are you menopausal? Yes_____ No_____ If yes, age of menopause Do you currently take hormone replacement? Yes___ No___ If yes, what type and for how long? ______ Estrogen Ogen Estrace Premarin Progesterone Provera Other ________________________________ FAMILY HEALTH HISTORY Please indicate current and past history to the best of your knowledge REVIEW OF SYMPTOMS Check those items that applied to you in the past. Circle those that presently apply (√) General Dryness/cracking skin Oiliness Fever Itching Chills/Cold all over Acne Aches/Pains Boils General Weakness Hives Difficulty sweating Fungus on Nails Excessive Sweating Peeling Skin Swollen Glands Shingles Cold hands & Feet Nails Split Fatigue White Spots/Lines on Nails Difficulty falling asleep Crawling Sensation Sleepwalker Burning on Bottom of Feet Nightmares Athletes Foot No dream recall Cellulite Early waking Bugs love to bite you Daytime sleepiness Bumps on back of arms & front of thighs Distorted vision Skin cancer SKIN: Strong body odor Cuts heal slowly Is your skin sensitive to: Bruise easily Sun Rashes Fabrics Pigmentation Detergents Changing Moles Lotions/Creams Calluses Eczema HEAD: Psoriasis
Are you menopausal? Yes_____ No_____ If yes, age of menopause Do you currently take hormone replacement? Yes___ No___ If yes, what type and for how long? ______ Estrogen Ogen Estrace Premarin Progesterone Provera Other ________________________________ FAMILY HEALTH HISTORY Please indicate current and past history to the best of your knowledge REVIEW OF SYMPTOMS Check (√) those items that applied to you in the past. Circle those that presently apply General Fever Chills/Cold all over Aches/Pains General Weakness Difficulty sweating Excessive Sweating Swollen Glands Cold hands & Feet Fatigue Difficulty falling asleep Sleepwalker Nightmares No dream recall Early waking Daytime sleepiness Distorted vision SKIN: Cuts heal slowly Bruise easily Rashes Pigmentation Changing Moles Calluses Eczema Psoriasis Dryness/cracking skin Oiliness Itching Acne Boils Hives Fungus on Nails Peeling Skin Shingles Nails Split White Spots/Lines on Nails Crawling Sensation Burning on Bottom of Feet Athletes Foot Cellulite Bugs love to bite you Bumps on back of arms & front of thighs Skin cancer Strong body odor Is your skin sensitive to: Sun Fabrics Detergents Lotions/Creams HEAD:
Health-History-Form-patient-1.docx