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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? __________________ |
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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: |
