Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Date of Birth
-
Year
-
Month
Day
Date
Gender
Please Select
Male
Female
Transgender to Male
Transgender to Female
Prefer not to disclose
Place of Birth
City/State or Town/Country if not in the US
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Drug Allergies
Genetic Background
Caucasian
African American
Hispanic
Asian
Mediterranean
Native American
Jewish
Northern European
Other
Education
High School
Under-graduate
Post-graduate
Some College
Other
Occupation/Job Title
Tell me a little about your day-to-day work life
Patient Birth History (if known):
Vaginal delivery
C-section
Full term
Premature
Breast-fed
Bottle fed
Unknown
Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Personal Medical History
Rows
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other
Personal Medical History cont.
Rows
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Herpes - genital
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Personal Medical History cont.
Rows
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Medication history
Rows
Currently
Past use
Rarely used
Never
NSAIDs (Advil, Motrin, Ibuprofen, Aspirin, etc.)
Tylenol (Acetaminophen)
Acid blockers (Tagamet, Zantac, Prilosec, etc.)
Antibiotics
Steriods
Oral contraceptives
Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Family History
Rows
Mother
Father
Sibling
Children
Mat. Grandparent
Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Please list any significant physical trauma you've experienced (this includes concussions, sports injuries, major car accidents/bodily injury, abuse etc):
Please list emotional trauma you've experienced in your life:
WOMEN'S HEALTH HISTORY
Pregnencies
Miscarriages
Abortions
Living Children
Number
Vaginal Deliveris
Deliveries via Cesarean
Gynecological Hx cont.
Post partum depression
Toxemia
Gestational diabetes
Baby over 8 pounds
Age at first period
Are you in menopause (12+ months since last period)?
Yes
No
Not sure
First Day of your last period?
-
Month
-
Day
Year
Date
Length of period in days:
Describe your flow (heavy, light):
Describe your symptoms near/during your period (cramping, moody, cravings etc.):
Gynecological Hx cont.
Rows
Present use
Past use
Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy
Gynecological Hx cont.
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
Mammogram in the last year?
Yes
No
Date of Mammogram:
-
Month
-
Day
Year
Date
Was it normal or were there abnormalities? (please describe or put N/A)
If you have not had a mammogram, are you waiving liability and the requirement for one?
Yes, I am waiving liability for the requirement for a mammogram and accept all consequences associated with lack of imaging and hormone therapies provided.
No, I am not waiving liability - I agree to have a mammogram completed prior to starting any hormone therapies.
Signature acknowledging response above
PAP smear in the last year?
Yes
No
Date of PAP smear:
-
Month
-
Day
Year
Date
Was it normal or were there abnormalities? (please describe or put N/A)
If you have not had a mammogram, are you waiving liability and the requirement for one?
Yes, I am waiving liability for the requirement for a PAP smear and accept all consequences associated with lack of testing and hormone therapies provided.
No, I am not waiving liability - I agree to have a PAP smear completed prior to starting any hormone therapies.
Signature acknowledging response above
Bone density scan in the last year?
Yes
No
Results of bone density scan:
Osteopenia
Osteoporosis
N/A
Please select any symptoms you are experiencing:
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
Thinning of skin
Dry/brittle Skin/Hair/Nails
Thinning of hair
Hair Loss
Night Sweats
MEN'S HEALTH HISTORY
Please select all that apply:
Prostate enlargement
Prostate infection
Change in libido
Impotence (complete inability to obtain an erection)
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Loss of Motivation
Loss of Lean Muscle Mass
Difficulty Gaining Muscle
Unexplained weight gain around midsection
Thinning Hair
Difficulty Concentrating
Other
Please explain any symptoms selected above:
If age 50+ has your prostate been evaluated via Digital Rectal Exam or Ultrasound
Yes
No
Date of last prostate exam:
-
Month
-
Day
Year
Date
Was it normal or were there abnormalities? (please describe or put N/A)Type a question
If you have not had a prostate exam and are over the age of 50, are you waiving liability and the requirement for one?
Yes, I am waiving liability for the requirement of a prostate exam and accept all consequences associated with lack of testing and hormone therapies provided.
No, I am not waiving liability - I agree to have a prostate exam prior to starting any hormone therapies.
Signature acknowledging response above
End of Gender Specific Health History/ BEGIN SOCIAL HISTORY
Current height:
Current weight:
Based on the image above, what is your current body type? (Are you more rectangular, triangular or oval shaped?)
Where do you carry most of weight? (Select all that apply)
Chest/Upper Body
Belly/Midsection
Hips/Butt
Thighs/Lower body
What was your weight and body type around age 25?
Smoking History:
Current
Past
Never
Second-hand smoke exposure
If current smoker, how many packs/day?
If current smoker, for how many years?
If past smoker, for how many years?
Do you consume alcohol?
Current
Past
Never
If current, how many drinks per day? (if not daily put N/A)
If current, how many drinks per week? (if not weekly put N/A)
If current, how many drinks per month?
If past drinker, was consumption mild, moderate, or high?
Mild
Moderate
High
Drink(s) of choice (select all that apply):
Vodka
Whiskey
Beer
Wine Cooler
Seltzer
Frozen
Other
Recreational Drug use:
Past
Present
Never
If past/present, what drugs?
Cocaine
Ecstacy/MDMA
Heroine
Meth
Marijuana
Other
if "other" please list:
Caffeine intake:
Coffee
Espresso
Soda
Tea
Energy Drinks
None
Other
Please list how many of each/day selected above and time of day:
How many hours of sleep do you average each night?
How many times do you wake throughout the night?
What is your normal bedtime?
What time do you typically wake?
Do you feel rested in the morning?
Sometimes
Always
Never
What sleep hygiene habits do you currently implement?
No caffeine after 1pm
No food after 8pm
Power down technology after 8pm
Blue Light Blockers
Red/Ambient light in the evenings
No TV in bedroom
Bedroom temp below 70 degrees
Sleep cooling system
Blackout curtains/pitch black room
Phone charging in a different room
Alarm clock with red numbers
Other
How many ounces of water do you drink daily?
Where does your water come from? (select all that apply):
Bottled
RO system
Berkey (or similar)
Tap
Other
Do you add any of the following to your water? (select all that apply):
Electrolytes
Minerals
Lemon
Crystal Light (or similar)
Other
Please describe your typical breakfast:
Please describe your typical lunch:
Please describe your typical dinner:
How often do you eat out?
How do you typically cook food? (select all that apply):
Microwave
Oven
Grill
Fresh
Pan
Air Fryer
Deep Fryer
Instant Pot
Other
What types of fats/oils do you cook with? (select all that apply):
EVOO
Coconut Oil
Avocado Oil
Canola Oil
Peanut Oil
Margarine
Butter
Ghee
Tallow
Other
Do you adhere to any of the following dietary lifestyles:
Keto
"Lazy" Keto
Paleo
Vegan
Vegetarian
Gluten-Free
Dairy-Free
Soy-Free
Corn-Free
Pescatarian
Whole 30
FODMAP
Atkins
Weight Watchers
Animal-based/carnivore
Other
Do you have any know food sensitivities/allergies? If so, please describe:
Do you experience cravings for any of the following?
Chocolate
Cheese
Salt
Sugar
Crunch
Bread
Other
How many bowel movements do you have daily? weekly?
Describe your typical bowel movement (select all that apply):
hard
small/pebble-like
loose
watery
yellow
light brown
dark brown
mucousy
long, soft, tapered
Do you suffer from any of the following? (select all that apply)
constipation
diarrhea
IBS
IBD
gas/bloating
heart burn/indigestion
Other
Supplements (including herbs, minerals, vitamins, tinctures as well as dosages)
Medications - Please list dosages
Do you have active cancer?
Yes
No
Have you had cancer in the past 8 years?
Yes
No
By signing here, you confirm that the above is true to the best of your knowledge and accept all responsibility and liability for any adverse events that may occur as a result of withholding and/or falsifying information.
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