| | | Medical Form for the use of Natural Progesterone
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Medical History Form
Name____________________________ Date___________________________
Phone Number__________ email address _________________________
Date of Birth___________Age_____Height___________Weight___________
I. Give a History of your present disease. Please be detailed and
long winded. Take as much space as you want. If you need more room
copy this text to a word processor. We can also email you this form.
II. On a scale of 1 to 5, 5 being the worst and 1 being mild. Do you
have any of the following symptoms?
Hot Flashes
Night Sweats
Vaginal Dryness
Incontinence
Foggy Thinking
Memory Lapse
Tearful
Depressed
Heart Palpitations
Bone Loss
Sleep Disturbed Headaches
Aches and Pains
Fibromyalgia
Morning Fatigue
Evening Fatigue
Allergies
Sensitivity to Chemicals
Cold Body temperature
Sugar Craving
Elevated Triglycerides
Weight Gain - How many pounds?
Libido
Loss Scalp Hair
Increase Facial or Body hair
Nervous Irritable
Anxious
Water Retention
Fibrocystic Breasts
Uterine Fibroids
Weight Gain - Hips, abdomen,thighs
Cystic Ovaries
Endometriosis
Clinical Hypothyroid
III. List all the drugs you are currently taking.
III-5. Do you have a sensitivity to perfume? Are you sensitive to small amounts of drugs? Do you have low level anxiety?
IV. List all the nutritional supplements you are currently taking.
V. List any other problems you may have. Do you have Hypothyroidism?
If so Clinical Hypothyroidism or Laboratory Hypothyroidism?
Do you have thinning hair? Does your underarm hair take a long time to grow?
What is your temperature? Is it about 97F?
VI. Immune Status.
A. Do you currently have any active infections/abscesses?
B. Do you get any recurrent infections?
C. Are you currently taking any immunosupressive drugs?
VII. Xenoestrogen exposure.
A. How close do you live to farming areas?
B. What laundry detergent and dish washing detergent do you use?
Which clothes softeners do you use? Do you use bounce or the
equivalent in your dryer?
C. What bath soap and shampoo do you use?
D. How often and what percentage do you eat canned food?
E. How often and what percentage do you eat processed food? What
kind of processed food do you eat? What kind of containers does the
processed food come in?
F. How often and what percentage do you at conventionally grown
fruits and vegetables versus organically grown fruits and vegetables?
G. How often do you eat meat that is conventionally grown versus
meat grown without the use of pesticides or hormones?
H. How often and what kind of pesticides do you use? In the house or
in the yard?
I. Do your neighbors use pesticides?
J. How often and what kind of herbicides do you use? In the house or
in the yard?
K. Do you neighbors use herbicides?
L. What kind of tooth paste do you use?
M. Does anyone in your household take birth control pills or hormone
replacement therapy?
N. List the jobs that you have had in the past. Try to list
chemicals that you were exposed to during those jobs.
O. What do you drink and what containers are they in (plastic,
glass, juice box containers)? How much soda pop do you drink a week?
How much
juice do you drink per week? How much beer or wine do you drink?
If
you drink tap water, is it filtered? If filtered, what kind of
filtration do you use? What kind of coffee maker do you use?
P. Is your shower water filtered?
Q. Describe where you live:
R. Do you use a microwave oven to heat your food? .What do you heat
the food in? Plastic containers or dishes? What do you use to cover
the food while it is heating in the microwave oven?
S. What do you use to store your food in the refrigerator? How often
do you plastic containers to store your food?
T. What kind of fillings do you have in your mouth? (composite,
& gold) Do you have dentures?
U. How often do you use sunscreen?
V. Do you use shampoo with hormones?
W. What kind of dish washing detergent do you use?
X. What kind of make up do you use? Does it contain parabens?
Y. Do you use tampons? What kind of tampons?
Z. Can you trace the ONSET of your disease to a conflict with another woman? Can you trace the ONSET of your disease to an emotional/spiritual event? If so please elaborate here.
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