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1. Do you have osteoporosis, osteopenia, or told you have “thin bones”
or “bone loss”?
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Yes
No
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2. Are you receiving treatment for osteoporosis or bone loss?
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Yes
No
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If yes, describe:
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3. Do you suffer from urinary incontinence-losing urine or overactive
bladder?
|
|
Yes
No
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If so, how many episodes per day?
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|
4. Do you have hot flashes?
|
|
Yes
No
|
|
If so, how many episodes per day (day & night)?
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If yes, describe treatment:
|
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5. Are you experiencing vaginal dryness?
|
|
Yes
No
|
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6. Have you noticed a decrease in your sex-drive (libido)?
|
|
Yes
No
|
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7. Have you had a hysterectomy?
|
|
Yes
No
|
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If yes, when:
/
/
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8. Do you have a history of endometriosis?
|
|
Yes
No
|
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9. Do you have painful periods (menses) and/or pelvic pain?
|
|
Yes
No
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Date of last menses:
/
/
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10. Do you have fibroids?
|
|
Yes
No
|
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11. Do you suffer from Premenstrual Syndrome (PMS), such as mood swings
prior to menses?
|
|
Yes
No
|
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|
12. Do you have recurrent or frequent yeast infections or vaginal infections?
|
|
Yes
No
|
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|
13. Do you have heavy periods?
|
|
Yes
No
|
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14. Have you ever been diagnosed with a sexually transmitted disease?
|
|
Yes
No
|
|
If yes, describe:
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15. Are you interested in new birth control treatments?
|
|
Yes
No
|
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|
16. Do you have GERD (burning feeling in the mid stomach/chest)?
|
|
Yes
No
|
|
If yes, describe treatment:
|
|
|
17. Are you interested in a new weight loss treatment?
|
|
Yes
No
|
|
|
18. Would you be interested in receiving a vaccine that would prevent
Cervical Cancer, HPV, & Genital Warts?
|
|
Yes
No
|
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|
19. Are you experiencing chronic pain?
|
|
Yes
No
|
|
Where?
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|
If yes, describe treatment:
|
|
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20. Do you experience pain or discomfort during sexual relations?
|
|
Yes
No
|
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Of the above 20 questions which one is of most concern to you?
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I agree that this information may be placed in a physician’s database,
and I may be contacted for possible new treatments.
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