Health Assessment for Women

Name:

Date:

Mail:

1) Fatigue

Never Mild Moderate Severe

2) Mood Changes: Irritability, Anxiety / Nervousness, Depression

Never Mild Moderate Severe

3) Decreased Mental Ability: Memory Loss, Confusion, Loss of Focus

Never Mild Moderate Severe

4) Hot Flashes / Night Sweats

Never Mild Moderate Severe

5) Weight Gain: Bloating, Excessive Belly Fat, Inability to Lose Weight

Never Mild Moderate Severe

6) Decreased Sex Drive: Vaginal Dryness

Never Mild Moderate Severe

7) Sleep Problems: Can’t Stay Asleep, Can’t Fall Asleep

Never Mild Moderate Severe

8) Cold Hands & Feet / Always Cold

Never Mild Moderate Severe

9) Hair loss / Breakage

Never Mild Moderate Severe

10) Dry Wrinkled Skin

Never Mild Moderate Severe

Family History

Heart Disease

Yes No

Diabetes

Yes No

Osteoporosis

Yes No

Alzheimer's Disease

Yes No

Breast Cancer

Yes No