Bloom HRT Medical intake form

1
First things first- Do you live in Florida or Colorado?We are only licensed to see patients in these states.
YESNO
2
Name
First Name
Last Name
3
Email
example@example.com
4
Phone (used to process prescriptions & lab orders) We don't sell or give out your info.
example@example.com
5
Shipping AddressThe delivery address where you want your medications shipped to.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
What is Your Date of Birth?
7
If you're interested in testosterone, please type out your driver license or state ID number. We need this to process prescriptions for controlled substances. Otherwise skip.
8
HRT Labs are usually covered by insurance. We use Quest but can provide a lab slip you can take anywhere using your insurance.
Use QuestGet a Lab Slip
9
Please enter your insurance info.We don't bill insurance we simply pass the information to Quest who bills insurance.
Insurance Carrier Name (United/Blue Cross, etc)
Policy Number or ID Number
Group Number
Primary Policy Holder's Name
Your Relationship to Primary Policy Holder
Address of Primary Holder. If same write "same"
10
Are you experiencing any of these menopausal symptoms?Select all that apply.
Hot flashes
Night sweats
Fatigue
Weight gain
Brain fog
Sleep disturbance
Joint/Muscle pain
Memory problems
Other
None
11
Are you noticing any of these symptoms related to your vaginal health?Select all that apply.
Dry vagina
Irritation
Frequent infections
Itchy
Odor
Discolored skin in groin
Discharge
Painful
Other
None
12
Do you experience any of these bladder symptoms?Select all that apply.
Leak urine when cough. laugh or sneeze.
Have to pee constantly.
Feel like I have to pee after just having gone.
Burning on urination.
Frequent UTIs
Wake up more than once at night to pee
None
Other
13
When it comes to sex do you experience any of these?Select all that apply.
Lack of sensation/hard to orgasm
Painful intercourse
Not enough moisture/lubrication.
None
14
How would you describe your libido?Select all that apply.
Non existant
Low
Moderate
High
15
Our mood changes in menopause what are you experiencing?Select all that apply.
Increased anger/easily annoyed
Irritable
Anxiety
Mood swings
Depression
Want to be alone
Lack of motivation
Lack of interest in things
Other
None
16
Are you pregnant, lactating or trying to get pregnant?
YESNO
17
Women aged 50-74, have you had a mammogram in the past two years that showed no abnormalities?
YESNO
18
Do you have a history of polyps, fibroids or endometrial hyperplasia?
YESNO
19
When was your last period?
2-3 months ago
6 months ago
1 year ago
10+ years ago
20
Any period irregularities?
My cycles are shorter
I'm skipping cycles
Period is light and spotting
Heavier periods
Period never ends
Frequent break through bleeding
My IUD stopped my periods
Other
None
21
Do you have any unexplained vaginal bleeding?
YESNO
22
Have you had a hysterectomy, or ovaries removed?
Hysterectomy
Hysterectomy and both ovaries removed
Hysterectomy and one ovary removed.
None of these. I have my uterus and ovaries.
23
Have you had a uterine ablation?
No
Yes
24
Have you ever had an abnormal pap smear?
No
Yes
25
Do you have a history of breast cancer?
Yes currently being treated.
In remission
No history of breast cancer
26
Progesterone is formulated in peanut oil. Do you have a peanut allergy?Progesterone pills are peanut oil based.
YESNO
27
If you have taken hormone replacement therapy in the past did you ever have an adverse reaction to it?
YESNO
28
Briefly explain what happened.
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29
Please list any medication allergies. If none, type "none".
30
These conditions increase blood clot risk. Do you have any of following conditions?
Untreated high blood pressure
Current liver disease
Stroke and/or TIA
Heart attack
Blood clots
Current gallbladder disease
Deep Vein Thrombosis
Pulmonary Embolus
Limited mobility/wheelchair-currently
None
31
Please list all medications and supplements you're currently taking.
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32
Please list your current medical diagnosis.Example: diabetes, high blood pressure, high cholesterol, asthma, etc.
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Ok
33
Do you use tobacco products?
YESNO
34
What is your current height and weight?
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Ok
35
What is your blood pressure, if known?
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Ok
36
Do you have any questions for the nurse practitioner or is there anything she should know about your medical history?
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Ok
37
Please review and agree to consent for telehealth.* This field is required.
38
Please review and provide your informed consent for hormone treatment.* This field is required.
39
Please review and provide your acknowledgement of privacy practices.* This field is required.
40
Please review and provide your consent for subscription billing.* This field is required.Please review the brief document to understand what you're signing up for.
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