PATIENT INFORMATION PATIENT INFORMATIONName* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Date of Birth*Phone Number*Medicare Number*Reference Number*Expiry*Address*Email*Next of Kin: Name*Next of Kin: Phone*Next of Kin: Relation to you*How did you hear about us?Friend/Family ReferralFacebookGoogleDoctorNaturopath/otherRadioTVWalking PastChemist ReferralYellow/White PagesWhat symptoms have brought you to the clinic?*Please list any known allergiesPlease list current medicationsPlease list any longterm health issuesOperations History and YearHORMONE REVIEWDo you still have a menstural cycle?*YesNoWhat age did your menstrual cycle stop?What is the length of your menstrual cycleRegular 28 daysGreater than 28 daysLess than 28 daysIrregular/hard to tellDay 1 is the first day of your period. Have you had children?YesNoDid you have issues in pregnancy?Blood PressureBlood SugarOtherDid you have a history of misscarriage?YesNoAre you currently sexually active?YesNoDo you use contraception?YesNoAre you up to date with your Pap smear?YesNoHave you used hormone therapy in the past?HRTOral ContraceptivesImplantsOtherHORMONE SYMPTOMSMenopause Symptoms Select All Hot flushes/sweats Night sweats Disturbed sleep/Tossing and turning Angry/Irritable/Flying off the handle Low mood/anxiety/depression Stressed Unable to cope Foggy head/forgetful Fatigue/loss of vitality Low libido Dry vagina Abdominal Weight Gain Fluid Retention and Bloating Dry skin Creeping feeling under skin Pain on intercourse Period Issues Select All No period Heavy period Period Pain Angry/Irritable/Flying off the handle Low mood/anxiety/depression Stressed Unable to cope Headaches Fatigue Low libido PMS - Mood issues PMS - fluid and sore breasts PMS - bloating PMS - pimples PMS - sugar cravings Weight gain Fluid Retention and Bloating Dry skin Acne/Pimples Male pattern hair growth Pain on intercourse Other Issues Select All Hair Loss Issues with Temperature Regulation Pain on intercourse Menstrual spotting Sore breasts Gut issues/Bloating/reflux/gas Constipation/Diarrhoea Skin Issues Unexplained weight gain Feeling sluggish Sleep Issues AM Waking, 2am, 3am, 4am Mid morning and mid afternoon energy drops Body Pain Infertility Pain on intercourse Family HistoryMother: Please list any known health issuesFather: Please list any known health issuesYour Children: Please list any known health issuesYour Siblings: Please list any known health issuesHormone issues or cancers in the FamilyFemales on your mother's sideDiet and LifestyleDo you have any dietary restrictions?Glasses of alcohol per week.How many cups of coffee per day?Describe your intake of carbohydrate foodsLow CarbModerate CarbHigh CarbCarbohydrates include sweats, grains, fruits, vegetables, fruit juices, dried fruit, and anything sugary.
