Female Health History

Restoration Health Care

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Female Health History Form

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Please fill out and submit this female health history form prior to your initial appointment at Restoration Health Care. Feel free to call us in Hot Springs or Bentonville if you have any questions.

1) Patient’s legal name:*

2) Date of birth:*

3) Street address:*

4) City:*

5) Zip:*

6) Phone number:*

7) Email:*

8) Drug allergies:*

9) Name of insurance:*

10) Policy holder's name:*

11) Insurance policy number:*

12) Briefly describe your current problem or concerns:*

13) Date of last pap smear?

14) Rate: Feelings of depression:*

Yes

15) Heavy bleeding with your periods?*

Yes

16) Pain during intercourse?*

Yes

17) Rate: Decrease in libido:*

Yes

18) Rate: Decrease in physical stamina:*

Yes

19) Tired or fatigued?*

Yes

20) List current medication:*

21) List any past surgeries:*

22) History of breast lumps or fibrocystic breasts?*

Yes

23) Family history of breast cancer?

Yes

24) Date of last mammogram?*

25) Ever taken estrogen or testosterone in the past, if so please list?*

Yes

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Restoration Health Care

With locations in Hot Springs and Bentonville, AR, Restoration Health Care specializes in health and wellness services. Virtual appointments available. Same-day appointments. Walk-in appointments. Contact us today.

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