FEMALE EQUILUX QUESTIONAIRE

By Equilux™

701 E Main St #6 Moorestown, NJ 08057

PATIENT INFORMATION

Name:

Date

Date of Birth

Age

Weight

Height

PATIENT QUESTIONS

Currently pregnant or trying to conceive?

Yes No

Date of last mammogram:

Had menstrual cycle (within last 12 months)?

Yes No

Date of last menstrual cycle:

Had endometrial ablation?

Yes No

Is the patient on birth control?

Yes No

Name of birth control:

Has the patient had a hysterectomy?

Yes No

If so, type of hysterectomy:

Complete (uterus and ovaries removed) Partial (uterus only removed)

Is the patient currently utilizing BHRT or HRT?

Yes No

If yes, select types of Hormones:

Testosterone

Progesterone

Estrogen

Thyroid

List Name and Dose of Hormone(s):

Is the patient currently on statins?

Yes No

Is the patient a smoker?

Yes No

Is the patient currently on oral nitrates?

Yes No

MEDICAL HISTORY

Select all that apply:

Fertility:

Patient Wants to Maintain Fertility

Cardiovascular Conditions:

Heart Attack or Stroke (within last 6 months)

DVT or Blood Clot (within last 6 months)

Hypertension

Hyperlipidemia

Obstructive Sleep Apnea

Atrial Fibrillation

Tachycardia

Cancer:

Breast Cancer or History of Breast Cancer

Endometrial Cancer

Cervical Cancer

Ovarian Cancer

Thyroid Cancer or History of Thyroid Cancer

Meningioma Except for Basal Cell Carcinoma

Other Cancers?

Gynecological Conditions

Pre-Menstrual Syndrome

Endometriosis or History of Endometriosis

Fibrocystic Breast Disease

Fibroids or History of Fibroids

Polyps or History of Endometrial Polyps

Neurological Conditions:

Epilepsy or Seizure Disorder

Depression/Anxiety

MEDICAL HISTORY

Endocrine and Metabolic:

PCOS

Diabetes Type 2 or Insulin Resistance

Hyperthyroid

Hypothyroid

Multiple Endocrine Neoplasia Type-2

Organ Specific Conditions:

Liver Disease or History of Liver Disease

Kidney Disease or History of Kidney Disease

LAM (Lymphangioleimyomatosis)

Osteoporosis or Osteopenia

HIV

Hepatitis

Hemochromatosis

Pancreatitis or History of Pancreatitis

History of Gall Bladder Disease

SYMPTOMS AND CONCERNS

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