Health history questionnaire page 3
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at
. Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Date of Birth
HORMONAL QUESTIONS ESTROGEN (FEMALE ONLY) Check all that apply.
Periods are irregular and painful?
Periods have stopped (menopausal)?
Lethargy, fatigue, memory loss?
Vaginal dryness? Loss of libido?
Pain during intercourse?
Excess body hair?
Hot flashes/Night sweats?
Tension, irritability, anxiety?
Joint pains, stiffness?
Aging wrinkled skin?
HORMONAL QUESTIONS PROGESTERONE/ESTROGEN (Check all that apply)
Often constipated with infrequent bowel movements?
Stools are hard and compact?
Strain during bowel movements?
Indigestion, bloating or gas after eating?
Yellow color to urine without the influence of B vitamins?
Urine is cloudy and unclear?
HORMONAL QUESTIONS TESTOSTERONE (Male Only) Check all that apply.
Decreased urinary flow
Hot flashes and night sweats
Loss of muscle tone
Abdominal weight gain
Insulin resistance/high blood glucose
High blood pressure
Low HDL cholesterol
High LDL cholesterol
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