Wise Woman Wellness

Today's Date * First and Last Name * Date of Birth * Age * Postmenopausal * Primary Care Provider * Last Menses * Cycling every _____ days? * Regular cycles? Are you feeling better or worse? Symptoms Which of these are you taking? List new health issues or allergies since last visit: List new drugs or supplements since last visit: List new health issues for close family members since last visit:

Please consider the last 4 weeks when answering the following questions:

Are you experiencing hot flashes Please provide brief details Night sweats Please provide brief details Are you having heavy periods? Please provide brief details Insomnia/use of sleep aids Please provide brief details Fatigue Please provide brief details Breast tenderness Please provide brief details Incontinence Please provide brief details Constipation Please provide brief details. How many BMs per week? Diarrhea Please provide brief details Bloating and gas Please provide brief details Heartburn Please provide brief details Decreased libido/sexual pleasure Please provide brief details Vaginal dryness Please provide brief details Painful sex Please provide brief details Anxiety Please provide brief details Depression Please provide brief details Irritability & moody Please provide brief details Memory problems/foggy thinking Please provide brief details Pain in joints Where? Please provide brief details Pain in muscles Where? Please provide brief details Headaches Please provide brief details Migraines Please provide brief details Acne Please provide brief details Cold intolerance Please provide brief details Brittle nails Please provide brief details Dry eyes Please provide brief details Food cravings Please provide brief details Change in weight Please provide brief details Increase in belly fat/waist size Please provide brief details Increased facial hair Please provide brief details Loss of head hair Please provide brief details Increased allergies Please provide brief details What was the date of your last gyn exam/pap smear? Were the results normal? What was the date of your last mammogram? Were the results normal? What was the date of your last Dexa Scan (bone mineral density x-ray) Were the results normal? What was the date of your last thyroid labs? Results? What was the date of your last cholesterol test? Results? What was the date of your last Vitamin D test? Results? Who do you live with? What is your smoking staus? What is your alcohol use? Do you use recreational drugs? If yes, please explain. How much exercise do you get? How much caffeine do you consume in a day/week? How much water do you drink in a day? Do you drink diet or regular soda? Please describe how much you drink in a day/week and what is your preferred brand. What is your stress level? Please provide brief details Average hours of sleep per night? Is your sleep restful? Current employer: Average hours worked in a week: How would you describe your diet? If eating gluten free, what % of time? I practice relaxation breathing 4 or more times per day (4-7-8 breathing). Comments I practice some quiet and reflective "me time" each week. Comments I limit my alcohol consumption to one or two drinks a week. Comments I minimize simple carbohydrates and sweets (candy/cookies/soda). Comments I limit unprocessed foods (food that come in boxes, bags or cans). Comments I consume 7 to 12 half cups of fruits and vegetables per day. Comments I eat three meals a day and a few snacks to keep my blood sugar stable. Comments I don't eat the same foods more than once every 4 days. Comments I consume at least 25 grams of fiber daily. Comments I eat protein with every meal and snack. Comments I use extra lubricaiton with intercourse such as Liquid Silk if needed. Comments I continue to read and learn more about getting and staying healthy. Comments I consume at least 1000 mg. of Calcium, 500 mg of Magnesium and 2000 IU of Vitamin D daily (considering both diet and supplements). Comments I know how to decrease my stress as needed. Comments I plan my day so I have enough time to get things done without rushing. Comments I experience harmony in my relationships with others. Comments I have a good support network of family and friends. Comments I receive support through my spirtual or religious beliefs and practices. Comments I have NOT experience any major loss or trauma recently. Comments I remember to take my high-quality supplements every day. Comments I am working hard to take great care of me! Comments