Female New Patient Intake
Please complete the following form in its entirety:
Full Name
Date
Preferred Clinic location
Bozeman
Billings
Helena
Missoula
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Home Address
City
State
ZIP
Mobile/Cell Phone
May we send messages via text regarding appts to your cell?
Yes
No
Other Phone (home or work)
Email
May we contact you via email?
Yes
No
Weight
Goal Weight
Occupation
Date of Birth
Age
In case of emergency, who should we contact:
Relationship of Emergency Contact
Emergency Contact Phone #
Primary Care Physician (PCP)
PCP's Office or Contact Phone
Marital Status (check one)
Married
Divorced
Widow
Living with Partner
Single
Habits:
I smoke cigarettes or cigars
I drink alcoholic beverages
I use e-cigarettes
I drink more than 10 alcoholic beverages a week
I use caffeine
Activity Level
Low – sedentary
Moderate – walk/jog/workout infrequently
Average – walk/jog/workout 1 to 3 times per week
High – walk/jog/workout regularly 4+ times per week
Social:
I am sexually active
I have completed my family
My sex life has suffered
I want to be sexually active
I have NOT completed my family
I have not been able to have an orgasm or it is very difficult
I do not want to be sexually active
Birth control method:
Menopause
Hysterectomy
Tubal ligation
Birth control pills
Vasectomy
IUD
Infertility Menses
Other
Are you currently doing Hormone Replacement Therapy?
Yes
No
If yes, what hormone therapy are you doing?
List any past Hormone Therapy no longer receiving
Pertinent Medical/ Surgical history:
Brest cancer
Uterine cancer
Ovarian Cancer
Polycystic ovaries/PCOS
Acne
Exess facial/body hair
Infertility
Endometrisis
Epilepsy or seizures
Fibrocystic breast pain
Ulterine fibroids
Irregular or heavy periods
Menstrual migraines
Hysterectomy with removal of ovaries
Partial hysterectomy (uterus only)
Hot Flashes
Oophorectomy removal of ovaries only
List any other Cancer diagnosis:
Have you ever had any issues with local anesthesia?
Yes
No
Do you have a latex allergy?
Yes
No
Medications currently taking (list all w special attention to statins, thyroid or reductase Rx)
Drug Allergies
Family History
Heart disease
Diabetes
Osteoporosis
Alzheimer’s/dementia
Breast cancer
Other
Health Issues *
Thyroid Tumors
Acute Pancreatitis
Acute Gallbladder
Hypoglycemia
Type 1 Diabetes
Kidney Injuries
Hypersensitivity
Diabetic Retinopathy
I am currently taking Insulin
Increase in Heart Rate
Suicidal Behavior
Medical history
High blood pressure or hypertension
Heart disease
Atrial fibrillation or other arrhythmia
Blood clot and/or a pulmonary embolism
Depression/anxiety
Chronic liver disease (hepatitis, fatty liver, cirrhosis)
Arthritis
Hair thinning
Sleep apnea
High cholesterol
Stroke and/or heart attack
HIV or any type of hepatitis
Hemochromatosis
Psychiatric disorder
Thyroid disease
Diabetes
Lupus or other autoimmune disease
Hoshimoto’s Disease
Joint Issues (select all you have ever had issues with)
Spine
Neck
Shoulders
Knees
Hips/pelvis
Hands/wrist
Ankle/feet
Please list any other information you feel would be helpful for the medical staff
Signature
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