Female Patient Questionnaire Female Patient Questionnaire If you are human, leave this field blank. Name * First Last * Last Age * Email Address * Phone Number Address * Street Address Line 1 Street Address Line 2 Street Address Line 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Please list any specific issues. Check all that apply to you Hot Flashes Night Sweats Vaginal Dryness Foggy Thinking Memory Lapse Mood Swings Breast Tenderness Water Retention Irritability Anxiety Tearfulness Depression Disturbed Sleep Headaches Low Sex Drive Cold Body Temperature Fatigue Blunted Motivation Diminished Feeling of Well-Being Prolonged Fatigue Muscle Weakness Please list any medication allergies you may have. Have you ever had female organ cancer? * Yes No Please lise any medications you are currently taking. Are you pregnant or do you think you might be pregnant? * Yes No Have you had a blood clot in your lungs or legs? * Yes No Are you currently using tobacco products or have a history of tobacco use? * Yes No
