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Women's Heart & Vascular Health
Center for Women's Heart & Vascular Health
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You Should Know

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Information to Share with Your Doctor - Worksheet

Use the Easy Print Format button below to print the worksheet or use the Email button above to share this web page with a friend. This worksheet is also available as a PDF in English and Espanol.

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


Do you have
high blood pressure?

Do you take medicine for
high blood pressure? _____

Do you take medicine
for high cholesterol?


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
or peripheral vascular

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


Have you ever been diagnosed
with Lupus or
Rheumatoid Arthritis?

___Yes  ___No


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