Hormone New Patient Form

Hormone New Patient Form

Please complete all sections accurately to help us provide you with the best care.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
E-mail
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Employer Information
Job Title
How did you hear about Vitality Hormones & IV Bar?
If referred by a patient, please list name here
Has your doctor ever said your blood pressure was too high or too low?
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?
Has your doctor ever told you that your cholesterol was too high?
Have you (or a family member) ever been told that you have diabetes?
Have you ever been diagnosed with an autoimmune condition?
Please provide details (autoimmune condition)
Have you ever been diagnosed or treated for a Thyroid condition?
Do you have any injuries or orthopedic problems (back, knees, etc)?
Do you have stiff or swollen joints?
Do you have tension or soreness in any area?
Are you allergic to any medication or food?
List all known allergies, and describe the specific reaction associated with each one.

Are you taking any prescribed medications or dietary supplementation?
Please provide details of the medications / supplements you are taking and the doses
Do you drink Alcohol?
Do you use Tobacco Products (Cigarettes, Dip, Vape)?
Do you use recreational drugs?
Have you been on hormone replacement therapy in the past?
Do you ever have problems sleeping?
Please provide details (sleep problems)
Have you had a hysterectomy or ablation?
Do you have regular menstrual cycles?
Please describe your cycle (Heavy, Light, Painful, or Irregular). How many days do they last?
Date of Last Menstrual Cycle

MonthDayYear
Date
Date of Last Mammogram

MonthDayYear
Date
Last Pap Smear Completed

MonthDayYear
Date
Do you wish to have more children? (Man or Woman)
Are you currently breast feeding?
Do you have a personal history of Cancer?
If yes, please list the type of cancer.
Does anyone in your family have a history of Cancer?
If yes, please list the type of cancer.
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?
Do you have any other genetic or medical conditions, injury or anything else we should be aware of that we have not mentioned?
If yes, please describe other genetic or medical conditions, injury, or other concerns
Please list your current reasons for seeking treatment at Vitality Hormones & IV Bar
Symptoms (check all that apply)
Services of interest (check all that apply)
I am choosing to purchase my labs from Vitality. My base cost will be $495.00.
I am choosing to submit my insurance card for the lab to bill my insurance provider. My base cost will be $295.00.
Date

MonthDayYear
Date
Signature of Patient
Should be Empty: