• 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.

  • Patient Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Current Medications / Supplements

  • Are you currently taking any medications or 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*

  • Reproductive Anatomy

  • Do you have a uterus?*
  • Do you have a cervix?*
  • Do you have both ovaries?*
  • Do your overall symptoms seem to change with your menstrual cycle? Are they worse at certain times of the month?
  • Pregnant / planning pregnancy*

  • Menstrual & Menopause History

  • Menstrual status*
  • Painful periods?
  • Spotting between periods?
  • Change in period length?
  • Change in period frequency?
  • Very heavy period?
  • PMS?
  • Diagnosed with PMDD?

  • Screening & Test History

  • Recent labs or screening tests to review?*
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  • 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
     - -
  • Ever been pregnant?*

  • Sexual Health

  • Are you sexually active?
  • Do you have concerns about your sex life?
  • Do you experience pain with intercourse?
  • When did the pain start?
     - -
  • Is the pain

  • 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?*

  • Attitudes & 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?

  • Signature & Consent

  • Date Signed*
     - -
  • Should be Empty: