Please enable JavaScript in your browser to complete this form.Full NameFirstLastEmail AddressPhone NumberDate of BirthAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMedical History - Check all that applyHigh blood pressureDiabetesThyroid disorderPCOSEndometriosisIrregular periodsBreast cancerOvarian cystsOsteoporosisDepression/anxietyMigrainesBlood clots/DVT periods experiencing Birth Relevant Medical HistoryCurrent MedicationsKnown AllergiesAge of first periodAre your periods regular?YesNoDate of last menstrual period (LMP)Birth control method (if any)Number of pregnanciesMenopause status:PremenopausalPerimenopausalPostmenopausalDo you currently use:Tobacco?Alcohol?Recreational drugs?Have you been diagnosed with or experiencing the following?Hot flashesFatigueLow libidoVaginal drynessMood swingsHair lossWeight gainBrain fogInsomniaPlease check any family history of the following conditions:Breast/ovarian cancerHeart diseaseDiabetesOsteoporosisDo you exercise regularly?YesNoAre you currently pregnant or breastfeeding?YesNoN/ADate of last period (if applicable)Are your cycles regular? YesNoN/AWhat are your main health concerns or goals?Consent and AcknowledgementI acknowledge that the information provided above is accurate to the best of my knowledge.I consent to treatment and understand that this form is part of my medical record.Signature (Consent) Clear Signature Date / TimeDateTimeSubmit
