Clone of Connected Membership Intake Form

Getting Started

Please complete this confidential form to help me understand your current concerns. After I receive your submission, I will be in touch within two business days to arrange bloodwork and schedule your first visit. I look forward to helping you optimize your health during this powerful stage of your life!
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Email address*
example@example.com
Phone number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Connected Wellness Center?*
What are your current concerns related to perimenopause or menopause? What have you already tried that helped or didn't help?*
Please upload results of any recent bloodwork related to your general health and hormone health.

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When was your last menstrual period?*
If you still get a period, are your cycles regular or irregular?*
Do you have a personal history of cancer of any type, abnormal blood clots such as DVT or PE, heart disease, vascular disease, or liver disease?*

Cancer of any typeAbnormal blood clot (deep vein thrombosis/DVT, pulmonary embolism/PE, etc.)Heart disease or vascular diseaseLiver diseaseNone of the above
If you answered yes to any of the above conditions, please describe:
Do you smoke cigarettes currently, or have you been a regular smoker in the last five years?*

YesNo
When was your last routine check-up with a primary care provider?*
When was your last Pap smear?*
When was your last mammogram? Have you ever had an abnormal mammogram? If so, please provide details.*
Please describe your medical history*
Please describe your mental health history*
Please describe your surgical history*
Please describe any major family medical history*
Describe major medical issues among first and second degree relatives including cancer, heart attack, stroke, diabetes, etc.
What medications are you currently taking, if any?*
What supplements are you currently taking, if any?*
Describe your current alcohol and drug use, if any. *
Describe your physical activity/exercise, and any goals you would like to meet in this area.*
Describe your diet/nutrition, and any goals you would like to meet in this area.*
Describe your sleep patterns, and any goals you would like to meet in this area.*
Describe any barriers you have now or foresee developing that may impede your ability to meet your health and wellness goals.*
Is there anything else I should know about you to help me support you more effectively?*
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Getting Started