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Align Wellness Center

2290 Ben Hill Rd SW
Atlanta, GA,30311
(404) 344-8853
Name: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you between the ages of 45-55? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you starting to notice hormonal changes throughout the month? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(Increased mood swings, irritability, insomnia, etc.)

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Are your cycles still regular? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have there been any recent changes in your cycle or the symptoms associated with your cycle? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please answer the following questions as best as you can based on your current experience.

 

What is the average length of your current menstrual cycle? (Counted from the first day of full bleeding to the first day of your next cycle, at full bleed) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you experienced any recent changes to your cycle with regard to timing, flow or duration? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How would you describe your typical menstrual flow? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you use pads or tampons? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What size tampons on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many tampons do you use on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What size pads on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many pads to you use on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you ever bleed through during the night? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you pass clots? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Approximately how large are the clots? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you spot? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you experience cramping? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you experience abnormal vaginal discharge? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you experience vaginal itching or odor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you experience itching on the labia? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you experience a change in breast size? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Check either 'Ongoing' or 'Just with Period' for each problem that applies to you.

Check BOTH if the problem is ongoing and worse with your period.

Then rate the severity.  

 

If neither apply, select 'N/A.'

 

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Depression/Low mood {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Blood sugar fluctuations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lowered self-esteem or self image {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Caring for others before yourself {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Memory difficulties {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Increased appetite/Constant hunger {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Caffeine/Stimulant cravings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Salt cravings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Headaches/Migraines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Back pain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight gain or difficulty losing weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight loss {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Water retention {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bloating/Belching/Gas {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stomach burning/Nausea/Indigestion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Constipation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Light colored stool {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Loose stool/Diarrhea/Constipation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Acne/Rashes/Brown spots {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Excessive facial or body hair {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Body or head hair loss {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Infertility {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Changes in libido {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hot flashes/Night sweats {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Palpatations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Breast tenderness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Nipple discharge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Vaginal or yeast infections {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Urinary incontinence or frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Changes to labia or clitoral tissue {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(atrophy, thinning, discoloration, itching, burning)

Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Vaginal changes (dryness, tearing, decreasing size) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you had a tubal ligation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently using any form of birth control? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you used any hormone contraceptives in the past? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently using any form of hormone contraception? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you used any kind of bioidentical hormones in the past? (over-the-counter or prescribed) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(DHEA, pregnenolone, estrogen, progesterone, testosterone)

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Are you currently using any kind of bioidentical hormones? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(DHEA, pregnenolone, estrogen, progesterone, testosterone)

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Have you ever had an abnormal pap test? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever had a vaginal infection? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have a history of having any of the following:

 

Ovarian cysts? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Uterine Fibroids? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fibrocystic breasts? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PCOS? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Endometriosis? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Vulvodynia? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lichen Sclerosis? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been pregnant before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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This document is for internal assessment only. You acknowledge that no patient-practitioner relationship has been established by submitting this document or providing any information through this website. If you have or suspect that you have a medical problem or condition, please speak with a qualified healthcare professional. If you think you are experiencing a healthcare emergency, you should call 911 or call for emergency services immediately.Insert and format text, links, and images here.

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Align Wellness Center

2290 Ben Hill Rd SW
Atlanta, GA,30311
(404) 344-8853
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Please answer the following questions as best as you can based on your current experience.

 

What is the average length of your current menstrual cycle? (Counted from the first day of full bleeding to the first day of your next cycle, at full bleed) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many days does your bleeding typically last? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How would you describe your typical menstrual flow? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you use pads or tampons? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What size tampons on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many tampons do you use on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What size pads on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many pads to you use on your heaviest days? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you ever bleed through during the night? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you pass clots? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Approximately how large are the clots? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Check either 'Ongoing' or 'Just with Period' for each problem that applies to you.

Check BOTH if the problem is ongoing and worse with your period.

Then rate the severity.  

 

If neither apply, select 'N/A.'

 

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Difficulty concentrating {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Memory difficulties {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Fatigue {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Increased appetite/Constant hunger {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sweet/Carb/Chocolate cravings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Caffeine/Stimulant cravings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Salt cravings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Headaches/Migraines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Back pain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight gain or difficulty losing weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight loss {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Water retention {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bloating/Belching/Gas {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Stomach burning/Nausea/Indigestion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Constipation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Light colored stool {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Loose stool/Diarrhea/Constipation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Acne/Rashes/Brown spots {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Excessive facial or body hair {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Body or head hair loss {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Infertility {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Changes in libido {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hot flashes/Night sweats {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Palpatations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Breast tenderness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Nipple discharge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Vaginal or yeast infections {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Urinary incontinence or frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Changes to labia or clitoral tissue {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Vaginal changes (dryness, tearing, decreasing size) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
More Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you had a tubal ligation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When did you have it done? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you currently using any form of birth control? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What type? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you used any hormone contraceptives in the past? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What type? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How long did you use them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you currently using any form of hormone contraception? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What type? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How long have you been using them? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Did you experience any kind of problems or unwanted side-effects from using birth control or other hormone contraception? If yes, please describe: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you used any kind of bioidentical hormones in the past? (over-the-counter or prescribed) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Which ones and for how long? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are you currently using any kind of bioidentical hormones? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Which ones and for how long? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you ever had an abnormal pap test? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What was the recommendation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever had a vaginal infection? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What type? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What type of treatment were you provided? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

Do you have a history of having any of the following:

 

Ovarian cysts? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Uterine Fibroids? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Fibrocystic breasts? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
PCOS? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Endometriosis? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Vulvodynia? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Lichen Sclerosis? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been pregnant before? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Ages of children: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of pregnancies: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of live births: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of miscarriages: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of premature births: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of cesarean sections: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of still births: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of abortions: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Number of ectopic pregnancies: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Details/complications: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Anything else you want me to know? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

This document is for internal assessment only. You acknowledge that no patient-practitioner relationship has been established by submitting this document or providing any information through this website. If you have or suspect that you have a medical problem or condition, please speak with a qualified healthcare professional. If you think you are experiencing a healthcare emergency, you should call 911 or call for emergency services immediately.Insert and format text, links, and images here.