The Menopause Clinic Medical Intake
Complete this medical intake form for The Menopause Clinic. Please answer all applicable questions as accurately as possible.
Patient Information
Patient Name
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First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Marital Status
Please Select
Married
Single
Domestic Partner
Separated
Divorced
Widowed
Other
Pharmacy and Address or Phone Number. Please note: Starting HRT often means frequent dosing changes, which can make mail-order pharmacies challenging, but we're happy to work with whichever pharmacy you choose
Allergies and Allergic Reactions. Include any food allergies, such as PEANUTS. If none, please type N/A or None
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Height
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Weight
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Nicotine Product Use in the last 12 months
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Yes
No
Alcohol use (per week)
Medical History
Medical conditions diagnosed by a healthcare provider
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Migraines
High blood pressure/hypertension
Stroke
High cholesterol
Heart attack
Heart disease
Blood clot in legs (DVT)
Blood clot in lungs (PE)
Atrial fibrillation or other irregular heartbeat
Diabetes (Type 1)
Diabetes (Type 2)
Prediabetes
Thyroid disease (hypothyroidism)
Thyroid disease (hyperthyroidism)
Polycystic ovary syndrome (PCOS)
Endometriosis
Uterine fibroids
Ovarian cysts
Breast cancer
Uterine cancer
Ovarian cancer
Colon cancer
Other cancer (specify below)
Osteoporosis
Osteopenia
Autoimmune disease (e.g., lupus, rheumatoid arthritis)
Depression
Anxiety
Bipolar disorder
Sleep apnea
Chronic kidney disease
Liver disease
Gallbladder disease
Seizure disorder
Blood clotting disorder
Early menopause (before age 40)
Surgical menopause (ovaries removed)
Other (specify below)
None
If you have had cancer in the past, this does not automatically mean you cannot use hormone therapy. However, it is important to review your individual risks and benefits. To help us fully evaluate your situation, please consider providing any relevant records prior to your visit, including biopsy reports and oncology notes. This allows us to have a more complete picture when discussing your options .If you choose, you may email these records to info@menopauselouisiana.com (HIPAA-compliant).
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I understand
Other diagnosed medical conditions not listed above. Please list N/A or None if not applicable
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Previous surgeries Please list N/A or None if not applicable
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Are you currently pregnant or planning a pregnancy?
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Yes
No
Menstrual & Menopause History
What is your current menstrual status?
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Premenopause (before menopause and having regular periods)
Perimenopause/menopause transition (changes in periods but have not gone 12 months in a row without a period)
Postmenopause (after menopause)
If you are postmenopausal, what type of menopause did you have?
Spontaneous
Surgical
Due to chemotherapy or radiation therapy
Age at last period
If you are still having periods, how often do they occur?
Regular
Slightly variable
Skipping cycles
Period length (days)
Are your periods painful?
Yes
No
If yes, how severe is the pain?
Mild
Moderate
Severe
Do you have spotting or bleeding between periods?
Yes
No
Has there been a recent change in how many days your period lasts?
Yes
No
Has there been a recent change in how often your periods occur?
Yes
No
Has your period recently become very heavy?
Yes
No
Do you have PMS problems?
Yes
No
Have you been diagnosed with PMDD?
Yes
No
Screening & Test History
Date and result of last Pap smear
Date and result of last mammogram
Date and result of last thyroid test
Date and result of last cholesterol test
Date and result of last A1c or glucose test
Date and result of last colonoscopy
Date and result of last bone density test
Birth Control & Pregnancy History
Birth control methods used (past or present)
None
Sterilization
Male partner had vasectomy
Birth control pill/ring/patch
IUD
Implant
Depo-Provera
Condoms
Natural family planning
Other
Do you currently need to use birth control? (Note: Hormone therapy does not prevent pregnancy.)
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Yes
No
Do you currently have an intrauterine device (IUD)?
Yes
No
What type is it?
Paragard
Mirena
Liletta
Kyleena
Skyla
Copper
Other
What month and date was the IUD placed?
Have you ever been pregnant?
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Yes
No
Number of premature births
Number of miscarriages
Number of living children
Pregnancy-related complications
Sexual Health
Are you sexually active?
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Yes
No
Do you have concerns about your sex life?
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Yes
No
Do you experience pain with intercourse?
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Yes
No
If yes, how long ago did the pain start?
What best describes the pain with intercourse?
Pain with penetration
Pain inside
Feels dry
Other
Perimenopause & Menopause Treatments
Are you currently on hormone therapy or birth control?
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Yes
No
Have you previously tried other therapies (including hormone therapy) for perimenopause or menopause?
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Yes
No
Were the other therapies helpful?
Yes
No
Other
General Health & Lifestyle
How would you rate your overall health?
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Excellent
Good
Fair
Poor
Major stressors in your life right now
Attitudes & Preferences
How do you view menopause?
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Positively. For example menopause means no more periods and no more worry about contraception. Menopause marks a new life phase.
Negatively. For example menopause means a loss of fertility and loss of youth.
Other
What are your current views on hormone therapy for menopause?
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Positive. Hormone therapy is appropriate for some women
Negative. I don’t support the use of hormone therapy
Other
Is there anything else you would like your healthcare provider to know?
Referral & Employer Info (Optional, no impact on care)
How did you hear about the clinic?
*
ABC News
Nola.com
Facebook
Instagram
Biz New Orleans Magazine
Google search
Friend or family member
Healthcare provider
Employer/workplace
Influencer - please list their name in the next section
Other
If you selected Other or Referral, please describe
Do you work for an organization that offers employee health or wellness benefits?
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Yes
No
Not sure
Are you interested in employer-offered perimenopause and menopause-related education or benefits?
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Yes
No
If yes, what organization do you work for?
Signature & Consent
Patient e-Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
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