Female Profile Questionnaire

Name: ___________________ Telephone: (        ) ____________ Date of Birth: ______________
E-mail address:___________ How did you find our web site? _________________

Please use separate sheet of paper if necessary.

1.) Are you currently taking hormones? Detail.

2.) Are you Premenopausal? Average length of cycles, i.e. 26, 27, 28 days?

3.) Are you Perimenopausal (irregular cycles)?

Last menses:

4.) Are you Postmenopausal?

Last menses:

5.) Are you trying to become pregnant? Fertility problem?

6.) List any PMS symptoms.

7.) Migraine headaches? How often? Occur on day # __of cycle.

8.) Have you had a partial or total hysterectomy?

9.) Detail problems before and after hysterectomy.

10.) Have you had a Functional Adrenal Stress Profile?

11.) Considering Natural Hormone Replacement Therapy?

12.) What is your purpose for this hormone evaluation?

13.) List history of hormone driven pathologies i.e., breast cancer, endometriosis.

14.) Circle any of the following that apply to you:

Anxiety, Panic, Depression, Disturbed Sleep, Thinning Skin, Poor Concentration,
Memory Lapses, Heart Disease, Artherosclerosis, Hot Flashes, Night Sweats,
Osteoporosis, Irregular Menstruation, Vaginal Thinning/Dryness, Painful Intercourse,
Slow Healing, Reduced Libido, Unexplained Weight Gain, Malaise, Lethargy, Fatigue,
Loss of Appetite, Increased Appetite, Hair Loss or Dry Skin.

15.) Difficulty in falling asleep?

16.) Does your mind race? Can’t turn off thinking?

17.) Are you physically unable to relax? Muscles feel tight?

18.) Do you recall your dreams? Are they vivid?

19.) Do you frequently have nightmares?

20.) Circle if there is a family history of osteoporosis, cancer or cardiovascular disease?

Please mail your completed Questionnaire to:

Daniel Bivins D.C., 1095 Scott Street, San Diego, CA 92106