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
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
What are your current concerns related to perimenopause or menopause? Please provide any relevant details.
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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 clot (deep vein thrombosis/DVT, pulmonary embolism/PE, etc.)
Heart disease or vascular disease
Liver disease
None of the above
Do you smoke cigarettes currently, or have you been a regular smoker in the last five years?
Yes
No
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
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Please describe your mental health history
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Please describe your surgical history
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Please describe any major family medical history
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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?
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What supplements are you currently taking, if any?
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Describe your current alcohol and drug use, if any.
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Describe your physical activity/exercise, and any goals you would like to meet in this area.
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Describe your diet/nutrition, and any goals you would like to meet in this area.
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Describe your sleep patterns, and any goals you would like to meet in this area.
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Describe any barriers you have now or foresee developing that may impede your ability to meet your health and wellness goals.
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Is there anything else I should know about you to help me support you more effectively?
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Submit
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