Menopause Club

August 25, 2011 By admin

Filed Under: Uncategorized


Personal Information:
Your Name:
Your Email:
Telephone :
Address:
City:
State:
Zip:
Brithdate

Family History
Heart Disease
Diabetes
Cancer

Your History of Disease:
Heart Disease
Cancer
Diabetes
Allergies
Lung Disorder
Blood Pressure
Cholesterol
Blood Disorder

Symptoms You Would Like to Improve?
Hot Flashes	N/A Mild Moderate Severe
Decreasing Memory	N/A Mild Moderate Severe
Fatigue	N/A Mild Moderate Severe
Depression	N/A Mild Moderate Severe
Difficulty Sleeping	N/A Mild Moderate Severe
Increased Fat Deposits	N/A Mild Moderate Severe
Headaches / Migraines	N/A Mild Moderate Severe
Vaginal Dryness	N/A Mild Moderate Severe
Nervousness / Anxiety	N/A Mild Moderate Severe

Menstrual Cycle:
Last Menstrual Cycle	Within 1 Month Within 1 Year Longer

Additional Comments: