Please answer each question or check the appropriate response. Are you currently pregnant? before or during period? __ yes __ no __yes __ no __before __during 2. The approximate date of your last j. Do you experience any of the menstrual period? following before your period? 3. Number of children _____ __ water retention __ breast tenderness 4. Number of pregnancies______ or swelling 5. Age of first period _______ __ depression __ irritability __food 6. Age of Menopause (if cravings __ migraines applicable)___________ k. Do you have bleeding between 7. Is your menstrual cycle periods? regular?_________ l. Do you have any discharge between a. Number of days from the start of periods? one period to the start of the next________________ b. Average number of days of flow ________ Please put a check mark by the c. the flow is: symptoms that pertain to you. light1 2 3 4 5 6 7 8 9 10 heavy __ coldness or numbness in the external d. The color is: __ red __dark red __ genitalia pale red __bright red __ brown __pain or swelling of the testicles e. are there blood clots ? __ premature ejaculation __ yes __ no __ erectile dysfunction h. Do you have pain/cramps? __ prostate enlargement i. Do you have nausea or vomiting g. issues __ before period __ during period __ period
Please answer each question or check the appropriate response. Are you currently pregnant? __yes __ no 2. The approximate date of your last menstrual period? 3. Number of children _____ 4. Number of pregnancies______ 5. Age of first period _______ 6. Age of Menopause (if applicable)___________ 7. Is your menstrual cycle regular?_________ a. Number of days from the start of one period to the start of the next________________ b. Average number of days of flow ________ c. the flow is: light1 2 3 4 5 6 7 8 9 10 heavy d. The color is: __ red __dark red __ pale red __bright red __ brown e. are there blood clots ? __ yes __ no h. Do you have pain/cramps? i. Do you have nausea or vomiting before or during period? __ yes __ no __before __during j. Do you experience any of the following before your period? __ water retention __ breast tenderness or swelling __ depression __ irritability __food cravings __ migraines k. Do you have bleeding between periods? l. Do you have any discharge between periods? Please put a check mark by the symptoms that pertain to you. __ coldness or numbness in the external genitalia __pain or swelling of the testicles __ premature ejaculation __ erectile dysfunction __ prostate enlargement g. issues __ before period __ during period __ period
initial_patient_intake_forms.docx