New Paperwork/Assigned male at birth
What name would you like to be called?
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What is your pronoun(s)? He/She/They
Legal name
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First Name
Last Name
Email
example@example.com
Cell Phone Number
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Area Code
Phone Number
The office can text me for things other than appointment reminders... such as test results.
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Yes
No
Other Phone Number
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Area Code
Phone Number
Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Pharmacy- be specific ie Walgreens SOUTH Sebring etc
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What is the nature of your visit?
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BRIEFLY tell me why you are here... you will be answering a bunch of questions...
If you are here for a problem, when did it start?
What have you done for the problem?
Did it help?
Have you seen another provider for this problem?
Any testing ordered?
Anything else?
Severity of problem, 1 mild, 10 is severe
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Medical History
Cardiovascular/ Heart and blood vessels
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None
High blood pressure
Low blood pressure
Irregular heart beat
Rapid heart rate
Slow heart rate
Heart Attack
Stroke
Blood clot
Cholesterol problems
Heart surgery
Stents in place
Multiple- I’ll explain.
Are you on a blood thinner?
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No
Yes
Metabolic
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None
Pre-diabetes
Diabetes, controlled
Diabetes, not controlled
Insulin resistance
Started when?
Cancer
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No
Yes
Where was the cancer? What year?
Allergies/Asthma/COPD
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No
Yes
Problems with eyes/ears/nose/throat?
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No
Yes
Thyroid disease
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No
Yes
I have Hashimoto's
Auto-immune Disease
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No
Yes
Which one(s)?
Liver disease/transplant?
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No
Yes
Kidney Disease/ transplant?
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No
Yes
Neurological Problems
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No
Yes
Mental Health
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None
Anxiety
Depression
Anxiety w Depression
ADD/ADHD
PTSD
other or multiple
Have you ever been told to not take hormones?
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No
Yes
ANY surgery?
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No
Yes
Is there a family history of any of the above?
No
Yes
I'm adopted
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Social History
Marital Status
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Single
Married
Widowed
Divorced
Have a significant other.
Smoking / tobacco history, including vaping
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Never smoker
I quit
Still using
Street Drugs
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No
Yes, regularly
Yes, socially
In my past
I needed treatment
Alcohol use
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No
Yes, socially
Yes, regularly
In my past
I needed treatment.
Exercise regularly
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Yes
No
How often do you exercise and for how long.
Typical Diet
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I practice medication/relaxation techniques/have hobbies I enjoy.
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Work
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I work
I am unemployed
I stay at home or retired
I am a student
I feel stressed.
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No
Yes, some
Yes, I have high stress
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Sexual History
Gender
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Male
Trans female
Gender non-binary
I'd rather not say
other/ or I'll explain.
Explain if not listed or want me know more.
Have you ever been sexually active?
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Yes
No
Yes, but I am abstaining now.
Sexual orientation
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Heterosexual/ straight
Lesbian/gay
Bisexual
Asexual
Pansexual
Questioning/curious
Would rather not say
I'll explain
Explain above if needed.
Any sexual complaints? Low libido, erectile dysfunction etc
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n/a
No
Yes
Explain your issues/ have you done anything to help.
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Symptoms:
Unusual penile discharge.
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No
Yes
Yes with itching
Yes with odor
Yes with a different color
Multiple complaints
Have you changed sexual partners?
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n/a
No
Yes
I have multiple sexual partners.
Rashes/sores/lumps
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No
Yes
Do you have chronic fatigue?
Do you have muscle weakness or decrease in stamina or performance?
Are you now or have you ever taken testosterone or any hormone therapy?
Explain or n/a
If you are over 50, when was your last PSA?
If you are over 50, have you had your prostate checked?
Have you been told you have a prostate problem?
Any family history of prostate cancer? If so, who?
I understand that taking testosterone may decrease or cause actual infertility. I am aware of these risks and accept them. I also understand that my fertility may remain and I cannot use taking testosterone as a form of birth control.
I understand.
I am a trans female or trans non-binary and would like hormone therapy.
No
Yes
I am trans but do not want hormones.
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Do you have any allergies? If so please list or state none.
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List ALL medications/ dose AND reason for the medication(s). If none, state none.
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List ALL supplements: If none state none.
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Is there anything else you need to talk with me about?
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Emergency Contact Name and phone number
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Insurance Carrier (Blue Cross/ Aetna etc or type none)
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Policy numbers- put all # that is on your card (group/policy etc)
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I am giving consent to be treated at Customized Wellness, LLC .
YES
If you have insurance you give consent for Customized Wellness, LLC to bill your insurance and provide any information needed in order to have aclaim paid. If you have insurance but do not wish to use it that is your right. Be aware, if you are coming in for alternative/ functional medicine insurance will not be billed...
Bill my insurance
Do NOT bill my insurance
I don't have insurance
I am here for alternative/functional medicine. My insurance will not be used.
Who may we discuss your medical information with? Please list their name(s) and phone number as well as their relation to you? Or, if you do not wish to share ANY medical information please state "none".
Signature
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