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 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
2 digit month, 2 digit day, 4 digit yearDate
Email address
example@example.com
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
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?
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?
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