BioTE Female Intake Form

BioTE Intake Form - Female Patient

Bioidentical Hormone Questionnaire & History
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Now

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Calculated Current Age (office use)
Medical Services Plan BC Care Card Number
Weight: current weight* Height: Height*
Occupation: Occupation
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family physician's name:Doctor's name . Phone: Area Code Phone Number . Address:Doctor's Address (if known)
Marital Status
Do you use any of the following (please check):Cigarettes Vape e-cigarettes Cigars None of the above Other
Please list any prescription medication you are taking, including doses:
Please list any supplements / vitamins you are taking, inculding doses:

Family Medical History. Please indicate if you have any family history of:

Medical History. Please indicate if you have a history of any of the following:

Rows	Yes	No	Unsure
High blood pressure / hypertension
High cholesterol
Diabetes or impaired glucose tolerance
Thyroid Disease
Stroke or heart attack
Atrial fibrillation or other arrhythmia
Blood clot or pulmonary embolus
COVID-19
Other lung disease
Snoring or sleep apnea
Anemia
Hemochromatosis
Multiple blood donations
Liver disease (hepatitis, fatty liver, cirrhosis)
HIV
Hepatitis B or C
Kidney disease
Arthritis
Osteoporosis
Autoimmune disease
Alopecia or other hair loss
Acne
Excess facial or body hair
Infertility
Endometriosis
Fibrocystic breast disease or breast pain
Uterine fibroids
Irregular or heavy periods
Menstrual Migraines
Hysterectomy with removal of ovaries
Hysterectomy partial (uterus only)
Oophorectomy (removal of ovaries)
Thyroid surgery
Depression/anxiety
Urinary Incontinence (eg. with sneezing, coughing, jumping)
Painful Intercourse
Difficulty Urinating
Breast Cancer
Uterine cancer
Cervical Cancer
Ovarian Cancer
Other Cancer

Preventative Medical Care. Please indicate if you have had any of the following:

Rows	Yes	No	Unsure
Medical/Gynecologic Exam within the last 12 months
Bone Density test within the last 12 months
Mammogram within the last 12 months
Pelvic ultrasound within the last 12 months
normal PAP test within the last 2 years

Is there anything else about your health or other circumstances that is important for us to know?
Signature
Should be Empty:

BioTE Intake Form - Female Patient