First Name *

Last Name *

Date of Birth *

SSN# or DL# *

Phone *

Email *

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Address

Street Address *

City *

State *

Country *

Postal code *

OCCUPATION:

What do you do for a living? *

EMERGENCY CONTACT:

Emergency Contact Person *

Relationship to Patient: *

Emergency Contact's Phone # *

HEALTH INSURANCE:

Do you have health insurance? *

Yes

Insurance Company: *

Policy Number:

PHARMACY INFO:

What is your preferred pharmacy? *

Pharmacy Location (City) *

HEALTHCARE TEAM:

Who is your Primary Care Provider? *

Who is your OBGYN? *

Do you have a preferred provider for your care with us? *

What is your PRIMARY concern? *

Hormone Replacement Therapy

Weight Loss

I'm not sure, I would like to do a Wellness Evaluation

Do you have a SECONDARY concern? *

Hormone Replacement Therapy

Weight Loss

No secondary concern

Are you interested in any of the following aesthetic services?

ALLERGIES & RESTRICTIONS:

Do you have any allergies to medications, foods, latex, dyes, etc? *

Yes

List all allergies and reactions *

What is your current height (inches)? *

What is your weight (pounds)? *

What was your weight at age 18? *

What is your goal weight? *

How long have you been struggling with weight gain? *

MEDICATIONS & SUPPLEMENTS:

Do you take any medications or supplements daily? *

Yes

List all current medications, doses, and reason for taking (ex. Losartan, 50mg daily, for blood pressure): *

Select ALL health conditions YOU currently have or have had in the past: *

Have you had any surgeries in the past? *

Yes

List all surgeries and associated dates *

Have you ever had a mammorgram? *

Yes

What was the date of your last mammogram? *

Estimate time frame if exact date is unknown

What was the result of your last mammogram? *

It is strongly recommended that all Women’s Wellness patients follow standard breast cancer screening guidelines starting at age 40, and that shared decision-making is recommended regarding screening frequency, taking into account HRT use as a risk factor. ALL patients on systemic hormone therapy are required to follow best practice guidelines and standards regarding mammogram screenings in order to be eligible for systemic hormone therapy.

I agree to keep my mammogram screenings current according to best practice guidelines and to report any abnormalities as soon as possible.

I do not agree to follow breast cancer screening guidelines. I understand this could make me ineligible for hormone replacement therapy.

How long ago was your most recent Pap smear, what was the result? *

Reproductive Health:

Do you still have a menstrual cycle/period? *

Yes

Date of your last menstrual period? *

Estimate start date if exact date is unknown.

How long does your menstrual cycle typically last? *

2-3 days

3-5 days

6+ days

How would you describe your menstrual cycle? *

is regular (every 26-32 days)

is irregular (sometimes 32+ more days apart)

is irregular and frequent (sometimes less than 25 days apart)

HORMONE REPLACEMENT THERAPY HISTORY:

Are you currently taking hormone replacement therapy or have you taken hormone replacement therapy in the past? (including oral estrogen) *

Yes

What type of HRT have you used in the past? *

Select all symptoms that you are experiencing: *

FAMILY HISTORY:

Select any conditions that you have a FAMILY HISTORY of: *

SOCIAL HISTORY:

Do you exercise? *

Yes

What type of exercise do you enjoy? *

How often do you exercise? *

2 or fewer times a week

3-4 times a week

5+ times a week

WEIGHT LOSS HISTORY:

Have you participated in a medical weight loss program or taken prescription weight loss medication in the past? *

Yes

Select any weight loss medications you have used: *

When was your last dose of weight loss medication? *

Do YOU HAVE ANY of the following conditions? Select all that apply. *

Medullary Thyroid Carcinoma (MTC)

Multiple Endocrine Neoplasia Syndrome type 2 (MEN2)

Problems with pancreas or kidneys

Type 2 Diabetes WITH diabetic retinopathy

Untreated depression or suicidal thoughts, or mental health issues

Currently pregnant or planning to become pregnant, or breastfeeding

I have NEVER had Medullary Thyroid Carcinoma (MTC) OR Multiple Endocrine Neoplasia syndrome type 2 (MEN2). I have NEVER HAD problmes with my pancreas or kidneys; I have NEVER had type 2 diabetes WITH diabetic retinopathy. I DO NOT HAVE untreated depression or suicidal thoughts. I AM NOT pregnant or plan to become pregnant. I AM NOT breastfeeding.

Does anyone in your family have any of the following conditions? *

I hereby affirm that, to the best of my knowledge, the information I have provided on this form is complete and accurate. I understand that omission of medical history or current medications may adversely impact the ability of my healthcare providers to deliver safe and effective care. I acknowledge that intentionally providing misleading or false information may result in denial of eligibility or termination of membership. *

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