Female Health and Lifestyle Questionnaire
Name(*)

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Email(*)

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Date(*)

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Age(*)

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Address(*)

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City, State, Zip(*)

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Home Phone #(*)

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Work Phone #(*)

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Cell Phone #(*)

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Fax #

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Date of Birth(*)

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Goals(*)

Invalid Input What are your expectations as a patient at RejuvinAge?

Medical and family history. Please check the appropriate answer or leave blank if not relevant.

Invalid Input Initial Comments (if required)
1. Cancer

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2. Diabetes

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3. Heart Disease

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4. Arthritis

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5. Liver Disease

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6. Elevated Cholesterol / Triglycerides

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7. Endocrine / Thyroid Abnormalities

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8. High Blood Pressure

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9. Bowel Disease

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10. Neurological Disease

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11. Lung Disease

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12. Kidney Disease

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13. Stomach Disease

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14. Blood Clots

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15. Weight Control Problems

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16. Osteroporosis / Osteopenia

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17. Anemia

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18. Alcohol

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19. Drug Abuse / Recreational

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Please explain any checked box.

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20. Surgical Procedures

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21. Serious Injuries, Accidents, or Serious Illness?

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22. Allergies to Medications or Drugs?

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23. Medications: Including Over the Counter and Hormones

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Medication # 1

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Medication # 2

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Medication # 3

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Medication # 4

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Medication # 5

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24. Supplements

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Supplement #1

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Supplement #2

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Supplement #3

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Supplement #4

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Supplement #5

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25. Marital Status(*)

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26. Number of Children(*)

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Number of People in Your Household(*)

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27. Occupation(*)

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28. Tobacco Use(*)

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If You Checked "Yes" to Smoking, Please Explain

Invalid Input Example 1: Currently smoke 2 packs/day for 10 years. Example 2: Previously smoked 2 packs/day for 10 years.
29. Alcohol Consumption: # of drinks per week.(*)

Invalid Input If you do not consume alcohol, please list "0".
30. Caffeine / Coffee / Tea / Soda: # per day:(*)

Invalid Input If you consume none of these, please input "0".
31. Water: Daily consumption (*)

Invalid Input Example: "8 glasses"

32. Fatigue(*)

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33. Skin Disorders(*)

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34. Visual Problems(*)

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35. Hearing loss / ringing in ears(*)

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36. Allergy Symptoms(*)

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37. Headaches(*)

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38. Spider or varicose veins(*)

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39. Lumps in neck, armpits, groin(*)

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40. Breast Lumps(*)

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41. Shortness of breath at rest(*)

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42. Shortness of breath with exertion(*)

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43. Palpitations(*)

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44. Abdominal Pain(*)

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45. Diarrhea(*)

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46. Constipation(*)

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47. Blood in stool(*)

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48. Black Stool(*)

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49. Difficulty Urinating(*)

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50. Leaking urine(*)

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51. Urinating at night(*)

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52. Sexually transmitted disease(*)

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53. Muscle, bone, or joint pain(*)

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Please explain any answer checked "Yes".

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54. Fluid retention in hands, legs, ankles(*)

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55. Abdominal Bloating(*)

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56. Indigestion(*)

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57. Reflux(*)

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58. Allergies(*)

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59. Food sensitivities(*)

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60. Please list food allergies

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61. Oily skin(*)

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62. History of acne(*)

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63. Excessive body hair(*)

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64. Boils or sty's (*)

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65. Joint Pain(*)

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66. Carpal tunnel / wrist / hand pain(*)

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67. Back or Spine problems(*)

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68. Difficulty in losing wieght(*)

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69. Lack of mental alertnes(*)

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70. Decreased self image(*)

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71. Memory Problems(*)

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72. Energy loss(*)

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73. Sleep Problems(*)

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Describe sleep problems (If applicable)

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74. Poor Concentration(*)

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75. Rapid mood swings(*)

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76. Dry hair(*)

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77. Brittle nails(*)

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78. Cold hands or cold feet(*)

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79. Hair thinning or falling out(*)

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80. Date of last Colonoscopy

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Date of last Bone Density

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Date of last Chest X Ray

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Date of last Rectal Exam

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Date of last EKG

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Female Hormone Quiz

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1. Do you suffer from disruptive hot flashes?(*)

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2. Are you experiencing uncharacteristic mood changes?(*)

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3. Do you have breast tenderness or sensitivity?(*)

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4. Do you suffer vaginal dryness?(*)

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5. Is intercourse painful?(*)

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6. Has you desire for sex decreased?(*)

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7. Has enjoyment from sex decreased(*)

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8. Has your complexion changed?(*)

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9. Do you feel more tired or fatigued than usual?(*)

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10. Do you have difficulty sleeping?(*)

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11. Have your periods become irregular? (*)

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12. Is sexual arousal diminished?(*)

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13. Do you have difficulty concentrating or remembering things? (*)

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14. Do you have joint or muscle aches?(*)

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15. Leaking Urine(*)

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16. Migraine Headaches(*)

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17. Premenstual tension or moods(*)

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18. Problems with birth control pills(*)

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19. Problems with Hormone Replacement(*)

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20. Birth control used

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Date of last Menstual Period?(*)

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Date of Last Pap Smear

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Date of Last Breast Exam

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Date of Last Mammogram

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Date of Last Bone Density

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