Female Patient Questionnaire - Alt Therapies Center

Name:

Date:

Date of Birth:

Referred By:

Are You Now, Or Have You Ever Used Birth Control Pills? Yes No

Do You Have PMS? Yes No

Do You Have Difficult Periods? Yes No

Do You Have Clots? Yes No

Any Vaginal Discharges Now, Or In The Past? Yes No

Do You Have, Or Have You Had Lumps In The Breasts? Yes No

How Many Pregnancies?

How Many Live Births?

How Many Cesarean Section (C-Section) Births?

Have You Had Any Miscarriages?

Have You Had Any Abortions?

Are You in Menopause? Yes No

If Yes, When Did It Start?

Do You Have Any Hot Flashes? Yes No

Have You Ever Had Any Cysts On The Ovaries? Yes No

Any History Of Fibroids On The Uterus? Yes No

Have You Had A Hysterectomy? Yes No

Any History Of Endometriosis? Yes No

Any History Of Rape? Yes No