Woman’s Confidential Anti-Aging Health History Forms

Please use the drop down box to choose the appropriate selection for each symptom.

Name*
First Last
Date*
Month
Day
Year
Date of Birth*
Month
Day
Year
Please complete this form in one sitting. Incomplete forms cannot be saved.
Please rate the following symptoms. Point Scale is: 0-None 1-Mild 2-Moderate 3-Severe 4-Very Severe
1. Hot flushes, sweating (episodes of sweating)*
2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)*
3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early*
4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)*
5. Irritability (feeling nervous, inner tension, feeling aggressive)*
6. Anxiety (inner restlessness, feeling panicky)*
7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)*
8. Sexual problems (change in sexual desire, in sexual activity and satisfaction)*
9. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)*
10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)*
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)*
Grand Total

Please complete this form in one sitting. Incomplete forms cannot be saved.