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At what age did you begin menopause, if you have? _____ |
Did you have a hysterectomy? _____ Were the ovaries removed? _____ If so, when? _____
Did you take hormones or hormone replacement therapy? _____ For how many years?_____ Did you take estrogen alone (for example, Premarin)? _____ Did you take estrogen and progesterone (for example, Prempro)? _____ |
Do you have diabetes? _____ |
Do you take insulin?_____
Do you have a history of gestational diabetes? _____ |
Do you have a history of high blood pressure during pregnancy (Preeclampsia)? _____ |
Notes: |
Do you have high blood pressure? _____ |
Do you take medicine for high blood pressure? _____ |
Do you take medicine for high cholesterol? _____ |
Notes: |
Do you smoke? _____ |
If so do you use tobacco daily? _____
If you no longer smoke, how long has it been since you quit? _____ |
Do you have any family history of coronary artery disease or peripheral vascular disease? _____ |
If so, which male relatives under the age of 55? __________________
If so, which female relatives under the age of 65? __________________ |
During the past month: Have you often been bothered by feeling down, depressed or hopeless? ___Yes ___No Have you often been bothered by little interest or pleasure in doing things? ___Yes ___No |
Notes: |
Have you ever been diagnosed with Lupus or Rheumatoid Arthritis? ___Yes ___No |
Notes: |