Hormonal Questionnaire Please set aside 10-15 minutes to answer all the questions below before your appointment with Dr Fatima Khan. Personal Details Name * First Name Last Name Email * Date of Birth * MM DD YYYY Age * Occupation * Marital Status * Symptoms Please tick if you have the following symptoms: * Hot flushes Night sweats Sleep disturbance Headaches Anxiety Mood swings Low mood Irritability Facial hair Hair loss Vaginal dryness Low libido/sexual desire Uncomfortable sexual intercourse Gut issues constipation/loose stools Bladder symptoms Premenstrual breast tenderness Premenstrual mood changes Increased allergies and/or skin rashes Joint pain and/or muscle ache Forgetfulness Reduced focus/concentration How have these symptoms impacted your quality of life? * No impact Little impact Moderate impact Severe impact Gynaecological & Obstetrics History Describe your menstrual cycle: * E.g. How many days do you bleed? What is your cycle length? Is your flow light/heavy? Do you get pain? Number of Children: * Please list age of children and birth details: * e.g. 6 years old - Cesarean, 10 years old Vaginal Are you currently using contraception * Yes No If yes, please specify: Are you currently using or have used Hormone Therapy (HRT) * Yes No If yes, please specify: Medical History Height (cm) * Weight (kg) * Blood Pressure * List any medical problems that other doctors have diagnosed: * Please include dates if possible Have you had a blood clot in the past? * Yes No Have you ever had breast cancer? * Yes No Have you ever fractured/broken a bone? * Yes No If yes to any of the above, please specify and list approximate date: List your current prescribed medications: * List your current over the counter medications, vitamins, herbs, supplements: * List any drug allergies and reactions you have had: * List any surgeries/hospitalisations * List any significant family medical history: Lifestyle Describe what you eat in a typical day: Breakfast: * Lunch: * Dinner: * Snacks: * Fluids: * e.g. Water, caffeine, soft drinks etc Do you consume alcohol? * Yes No If so, how many standard drinks and how often? Are you a current smoker? * Yes No How often do you exercise? What type of exercise do you do? How do you rate your stress levels? * Low Medium High Investigations When was your most recent mammogram? * When was your most recent cervical screening (Pap smear)? * Have you had a bone density scan (DEXA)? If yes, what was the result? Thank you for your time How did you hear about Dr Fatima Khan? Thank you! We look forward to meeting you at the appointment.
