Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

1. Date of last regular menstrual cycle
2. Length of cycle
3. Form of birth control
4. Number of children     Miscarriages     Stillbirths     C-sections
5. Date of Surgical menopause
    Removed: Left Ovary      Right Ovary      Uterus
6. Date of last Physical Exam:
7. Date of last Pap Smear:
8. Date of last Mammogram
9. Rate your perception of the level of female-related stress you are experiencing on a scale of 1 to 10 (0 - being the lowest, 10 being the highest): 0 1 2 3 4 5 6 7 8 9 10
10. Current health concerns:

11. Identify the major causes of current health concerns:


12. Family Medical History (check any that apply):

Breast or other cancers
Cardiovascular disease
Osteoporosis
Obesity
Alcoholism
Mental Illness/Depression
Alzheimer's
Diabetes
Arthritis
Stroke
Lumps, Cysts or Tumors     
      Where: Breast     Left Ovary      Right Ovary     Uterus

13. Prescription medications for female complaints, including hormone replacement therapy:


14. Female Dietary supplements, herbs or natural products:


15. Have you experienced unintentional weight loss or gain of 10 pounds or more in the last three months? Yes     No How many pounds?

16. Do you or are you:

Exposed to passive smoke? Yes     No
Use tobacco/smoke cigarettes? Yes     No
How many cigarettes per day?
Drink coffee? Yes     No
How many 8 ounce cups daily?
     Decaffeinated      Strong      Mild
Drink alcoholic beverages? Yes     No
     How many ounces per day? per week?
Type of alcoholic beverages you drink:

17. Regarding Exercise:

Do you exercise daily? Yes     No
      How many times per week?
Type of Activity:

18. Dietary Habits:

Do you restrict eating dietary fat? Yes     No
How many grams of fiber do you consume daily?
Do you eat dairy products? Yes     No
Do you eat animal protein? Yes     No
Do you have food cravings? Yes     No    Sometimes     
     If Yes/Sometimes, what do you crave?
How many meals do you eat per day?
Do you Diet Frequent? Yes     No Sometimes
Do you skip meals? Yes     No
     If yes, how many on the average do you skip weekly?
Have you tried a few or many fad diets in your attempts to manage or lose weight?
     Yes     No
Have you used diet drugs - prescribed or over-the-counter in your attempts to manage or lose weight? Yes     No

Additional Comments:

PART 1 - Check the symptoms you experience regularly one to two weeks before your period:

1. Anxiety
2. Irritability
3. Nervous tension
4. Aggressive or hostile toward family/friends
5. Self destructive behavior
6. Weight gain
7. Water retention
8. Abdominal bloating
9. Breast pain
10. Tender/swollen breasts
11. Craving for sweets
12. Increased appetite
13. Heart palpitations
14. Fatigue
15. Headaches
16. Shakes
17. Depressed
18. Withdrawn
19. Confused
20. Forgetful
21. Insomnia/difficulty sleeping

PART 2 - Check the symptoms and/or behaviors that occur during your period with a frequency or intensity that affects your daily activities:

1. Cramping in lower abdomen or pelvic area
2. Sharp intermittent pain
3. Dull aching pain
4. Upset stomach
5. Diarrhea
6. Nausea or vomiting
7. Low back aches
8. Headaches
9. Difficulty concentrating
10. Accident prone
11. Unusual fatigue (take naps)
12. Decreased productivity
13. Weight gain
14. Painful and/or swollen breasts
15. Irritability
16. Mood swings
17. Depression
18. Painful intercourse

PART 3 - Check off any of the following statements that describe your menstrual cycle, energy level or reproductive function:

1. Absence of periods for 3 months or more
2. Vaginal itching burning, dryness
3. Menstruation that occurs too frequently (every 21-24 days)
4. Irregular periods (once every three to six months)
5. Frequently skip periods
6. Menstrual cycle every 36 days or longer
7. Unusually light or heavy periods
8. Heavy prolonged menstrual bleeding
9. Menstrual bleeding lasts longer than 5 days
10. Unusually light menstrual flow -- "spotting"
11. Menses last for three days and are light.
12. Bleeding or spotting between period
13. Bleeding between periods is light- "staining"
14. Bleeding between periods is heavy
15. Abnormal vaginal discharge
16. Frequent urination

PART 4 - All Women Answer - Pre- or Post- Menopausal

1. Chronic fatigue
2. Irritability
3. Dizziness
4. Memory problems
5. Shortness of breath
6. Headaches
7. Bone pain

PART 5 - All Women Answer - Check any of the following symptoms if they occur with an intensity or frequency that affects your ability to perform your daily activities or feel good about yourself:

1. Decline of vital energy and sense of well-being
2. Hot flashes
3. Night sweats
4. Spontaneous sweating
5. Chills
6. Depressed
7. Irritable
8. Anxiety
9. Anger
10. Mood swings
11. Headaches
12. Forgetful
13. Difficulty concentrating
14. Difficulty sleeping
15. Urinary problems
16. Vaginal problems
17. Dry skin
18. Bleeding between periods
19. Irregular periods
20. Stopped menstruating
21. Joint and muscle pain
22. Change in sexual desire
23. Difficulty with orgasm
24. Painful intercourse
25. Loss of muscle tone

What concerns you the most (list in order of priority):

Copyright 1997 Lyra Heller MET 120 8/97