• The Menopause Clinic Medical Intake Form

    Complete this form as accurately as possible. This helps us understand your symptoms, medical history, treatment goals, and safety considerations before your visit.

  • Before you begin

    Please allow about 15–20 minutes to complete this form. You can stop at any time and return later. To save your progress, scroll to the bottom of the form and click the Save button before leaving.

    You’ll need a current government-issued photo ID to complete this form.

    Please submit your completed intake at least 24 hours before your visit to keep your appointment time.

    Why this matters: The more we know before your visit, the more time we can spend during your appointment focused on your symptoms, concerns, goals, and treatment options.

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Current Medications / Supplements

  • Are you currently taking any medications or supplements?*
  • Medications / Supplements
  • Have you ever been diagnosed with any of these, now or in the past*

  • Symptom Tracker

  • Mood swings*
  • Lack of desire or interest in sex and wanting to want sex more*
  • Pain or burning when urinating*
  • Bladder infections*
  • Vaginal dryness*
  • Vaginal itching*
  • Difficulty staying asleep*
  • Abnormal vaginal discharge*
  • Vaginal infections*
  • Pain during intercourse or orgasm*
  • Bleeding after intercourse*
  • Leaking urine*
  • Stomach bloating*
  • Weight gain*
  • Difficulty achieving orgasm*
  • Breast tenderness*
  • Joint pain*
  • New muscle mass loss or inability to gain muscle despite effort*
  • Poor memory*
  • Difficulty concentrating*
  • Hot flashes*
  • Night sweats*
  • Hair loss*
  • Difficulty falling asleep*
  • Palpitations or heart racing*
  • Itching*
  • Feeling more tired than normal*
  • Irritability*
  • Anxiety*
  • Depressed mood*
  • Crying spells*
  • Headaches*
  • Needing to urinate more frequently*
  • If you're having pain with intercourse or orgasm, where/what does it feel like?

  • Reproductive Anatomy

  • Do you have a uterus?*
  • Do you have a cervix?*
  • Do you have both ovaries?*

  • Menstrual & Menopause History

  • Menstrual status*
  • Painful periods?
  • Spotting between periods?
  • Change in period length?
  • Change in period frequency?
  • Very heavy period?
  • Pregnant / planning pregnancy*
  • PMS?
  • Diagnosed with PMDD?
  • Since going 12 months without a period, have you had any vaginal bleeding or spotting?
  • Do your overall symptoms seem to change with your menstrual cycle? Are they worse at certain times of the month?

  • Screening & Test History

  • Recent labs or screening tests to review?*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Birth Control & Pregnancy History

  • Birth control methods used
  • Do you currently need birth control?*
  • Hormone therapy does not prevent pregnancy.
  • Do you currently have an IUD?*
  • IUD placement month/year
     - -
    2 digit month, 2 digit day, 4 digit year
  • Ever been pregnant?*

  • Sexual Health

  • Any other sexual health concerns you’d like to discuss?

  • Perimenopause & Menopause Treatments

  • Current hormone therapy or birth control*
  • Previous perimenopause/menopause therapies tried*
  • Therapies tried
  • How helpful were the therapies

  • General Health & Lifestyle

  • Have you used nicotine products in the last 12 months?*

  • Goals & Preferences

  • Referral & Employer Info (Optional - does not impact care)

  • Interested in employer benefits info?
  • Would you like information about using HSA/FSA funds for clinic membership?

  • Identity Verification

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Signature & Consent

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: