Women's Health Questionnaire
Full Name
*
First Name
Last Name
E-mail Address
*
example@example.com
Contact Number
*
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Date of Birth
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
What pronouns do you prefer?
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Back
Next
Will anyone else be joining the Telehealth visit?
Yes
No
If yes, is there any topic you prefer to keep private, or avoid discussing, during this visit?
Back
Next
Reason(s) for Your Visit
Please describe the most important goal(s) you hope to achieve during this visit.
Back
Next
Past Medical and Surgical History
Have you ever been told you have a medical diagnosis or illness? (diabetes, high blood pressure, etc.)? If so, please describe.
Have you ever been hospitalized overnight or had surgery? If so, please describe.
Back
Next
Family History
What health conditions run in the family?
Back
Next
Reproductive Health History
Last Menstrual Cycle: If you have menstrual cycles, please choose the first date of bleeding during your most recent menstrual cycle.
-
Month
-
Day
Year
Date
Contraception
Are you currently using a birth control method to prevent pregnancy and/or regulate your menstrual cycle?
Yes
No
If yes, please indicate which of the following you use:
Birth Control Pills
Intrauterine Device
Birth Control Patch
Contraceptive Implant
Vaginal Ring
Depo Provera Shot
Diaphragm/CAYA
Withdrawal Method
Natural Family Planning
Condoms
Other
Pregnancy History
Have you ever been pregnant?
Yes
No
If yes, how many times have you been pregnant?
If you had any pregnancy complications, please describe them here.
Pregnancy Complications
Prior Fertility Testing or Treatment
Have you ever had infertility testing?
Yes
No
If yes, please choose any of the following testing that you (or your partner) have undergone for evaluation of fertility.
Labs (blood or urine) testing
Imaging (such as ultrasound)
Hysteroscopy
Laparoscopy
Semen Testing
Other
Have you ever had fertility treatment?
Yes
No
If yes, please choose any of the following treatments that you have undergone for treatment of fertility.
Fertility medications
In Vitro Fertilization
Intrauterine Insemination
Stress Reduction Techniques
Other
Have you ever been told that you have PCOS (Polycystic Ovarian Syndrome)?
Yes
No
Have you ever been told that you have Endometriosis?
Yes
No
Have you ever been diagnosed with a Sexually Transmitted Infection?
Yes
No
If yes, please choose any of the following that apply.
Chlamydia
Gonorrhea
Genital HSV
HIV
Syphilis
Trichomonas
HPV
Hepatitis
Other
Back
Next
Medications
Please list all medications that you take on a regular basis, including over the counter medications and supplements.
Allergies
Please list any medications or food allergies.
Back
Next
Social History
Who lives at home with you?
Are you employed? If so, please state your job title.
What is the highest level of education you achieved?
Elementary School
High School
College
Graduate/Professional School
Other
Are there any major stressors in your life recently? If so, please describe.
Do you use tobacco products?
Yes
No
Former smoker
Please describe what type of tobacco products you use, and how frequently.
Do you drink alcohol?
Yes
No
Please describe how many drinks of alcohol you have in an average week.
Do you use any other substances?
Yes
No
Please describe any other substance use.
Have you ever been informed of an exposure to environmental toxins?
Back
Next
Review of Systems
Please tell us about any of the following symptoms you may have experienced recently. Select all that apply. If you prefer not to answer, these can also be discussed at your visit.
General Physical Symptoms:
Chest pain
Trouble Breathing
Bladder problem (frequent infections/incontinence/other)
GI problem (constipation/diarrhea/other)
Appetite changes
Pain
Heartburn
Limited Mobility
Eye problem
Trouble hearing
Skin problem
Anxiety/Depression/Mood swings
Other
Additional Symptoms:
Irregular or absent periods
Painful periods
Excessively long periods
Vaginal bleeding between periods
Trouble getting pregnant
Hot Flashes
Trouble Sleeping
Night Sweats
Hair loss
Excess hair growth (chin, face)
Acne
Decrease Libido
Sexual problems
Weight gain/loss
Abdominal Bloating
Brain Fog or Memory issues
Irritability
Other
Is there anything else you would like us to know prior to your visit? If so, please provide that detail below.
Submit
Should be Empty: