Patient Intake / Wellness Intake

Patient Intake / Wellness Intake
Full Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
What is your gender?
Contact Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedWidowed
Height
Weight
Occupation
Pharmacy Number
Please enter a valid phone number.
Insurance Provider    Insurance Provider
Insurance Type      Insurance Type
Deductible   Deductible Amount
Deductible met Yes.
Deductible met No
Upload a copy of your insurance card
Upload recent or relative labs from the last 12 months
Check the allergies that apply to you:

PennicillinDye AllergiesAsprinSulfa DrugsPet AllergiesMorphineCodeineNitrate AllergiesFood AllergiesSesonal (pollen) AllergiesOther
Please describe any allergic reaction you experience:
Doctors Name

First NameLast Name
Doctors Phone #
Please enter a valid phone number.
Doctors Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List Current Prescription Medications, Current Nutritional Supplements (Please bring any nutritional supplements you take to your consultation)
What Hormones have you previously taken/
Have you ever used oral contraceptives? If yes any problems?
Have you ever had either of the following?

MammogramPap SmearOther
When was your last cycle or first day of last cycle and how many days did it last?
Do you have, or have you ever had PMS. if yes please explain
Have you ever had abnormal cycles?
How many pregnancies have you had?
How many children have you had?
Please select any that are applicable

Any interrupted pregnanciesHave you had a hysterectomyOvaries removedHave you had a tubal ligation
Check all that apply

AllergiesarthritisAsthmaCancerClotting ProblemsDepressionDiabetesEczemaFibrocystic BreastUlcersAnxiety DisorderStrokeHeart DiseaseHigh Cholesterol or lipidsHigh Blood PressureEye DiseaseMigraines/ HeadachesOsteoporosisThyroid DiseaseUlcersEmphysema / COPDFibromyalgiaGERDSeizure DisorderIrritable Bowel SyndromeOther
Did any of your immediate family have any of the disorders on the previous list? If yes, which ones?
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Below please indicate your symptoms (0-5) for the following conditions by using the following numeric scale: 0 being no symptoms at all and up to 5 bing the worst symptoms imaginable (please select the number in the field below
Fibrocystic Breast
Weight Gain
Fibrocystic Breast
Heavy Irregular Menses
Hot Flashes
Dry Skin / Hair
Anxiety
Depression
Night Sweats
Vaginal Dryness
Headaches
Irritability
Mood Swings
Breast Tenderness
Sleep Disturbances / Insomnia
Fluid Retention
Breakthrough Bleeding
Fatigue
Memory Loss
Incontinence / Frequent Urination
Arthritis
Difficulty Reaching Orgasm
Decreased Libido
Hair Loss
Indigestion
Cold Hands/Feet
Diarrhea and / or Constipation
Erectile Dysfunction
Failed Morning Erections
Urinary Retention
Urinary Frequency (night-time especially)
Food Sensitivity / Allergy
Heat / Cold Sensitivity
Difficulty Waking Up
What are your goals with taking BHRT / Wellness Testing
Please state any specific questions related to BHRT / Wellness Testing that you may have.
By signing your name we will accept this signature and acknowledge that you have read and reviewed this questionnaire.

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Patient Intake / Wellness Intake

Below please indicate your symptoms (0-5) for the following conditions by using the following numeric scale: 0 being no symptoms at all and up to 5 bing the worst symptoms imaginable (please select the number in the field below