Health History Intake Form

Health History Intake Form

Please complete this form with your current and past health information. Your responses are confidential and will help us provide the best care possible.
Personal Information

Tell us about yourself.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleOther
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical History

Share your medical background.
Have you been diagnosed with any of the following conditions?

DiabetesHypertension (High Blood Pressure)Heart DiseaseAsthmaCancerNone of the aboveOther
Please list any surgeries or hospitalizations (include dates if possible)
Current Medications (include dosage and frequency)
Allergies

Let us know about any allergies you have.
Do you have any allergies?

No known allergiesMedicationsFoodsEnvironmental (e.g., pollen, latex)Other
If you selected any allergies, please list and describe the reaction(s)
Lifestyle Habits

Your lifestyle can affect your health.
Hormone questionnaire

Please answer the following questions related to your hormone health.
Have you experienced any hormone-related symptoms?*

FatigueMood swingsWeight gainHot flashesNight sweatsHair lossIrregular periodsLow libidoOtherOther
Have you been diagnosed with any hormone disorders?*

YesNo
Which hormone treatments have you undergone?
Date of last hormone panel test

MonthDayYear
Date
Do you smoke or use tobacco products?

YesNoFormer user
Do you drink alcohol?

YesNo
How often do you exercise?
Emergency Contact

Who should we contact in case of emergency?
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.

Health History Intake Form

Personal Information

Medical History

Allergies

Lifestyle Habits

Hormone questionnaire

Emergency Contact