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Weight Loss
Compounded GLP-1
Fat Burner/B12
Appetite Suppressant
Sermorelin
Bella Capsules
Lab Testing
Injections
Sermorelin
NAD+
Glutethion Injections
Contact
Women’s Health Questionnaire
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*
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Personal Information
Full Name
*
Email
*
Phone number
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Other
Height
Feet
*
Inches
*
Weight
*
How Did you hear about us?
Emergency Contact Name & Phone
Name
*
Phone
*
Consent to receive automated messages/reminders:
Texts
Calls
E-mails
Marital Status
*
Married
Single
Divorced
Other
Other Status
*
Living Situation
*
Spouse
Alone
Partner
Parents
Children
Other
Other Living Situation
*
How would you rate your current general health?
*
Excellent
Good
Fair
Poor
Medical History
Do you have Current or past history of any of the following?(Check all that apply)
High blood pressure
Diabetes (Type 1 or 2)
High cholesterol
Heart disease
Stroke
Sleep apnea
Depression or anxiety
Thyroid disorder
Hashimoto’s Thyroiditis
Fibromyalgia
Kidney or liver disease
Seizure disorder
Cancer
Arthritis
MTHFR gene mutation
Hormone Imbalance
Blood clot(DVT/PE)
Varicose Veins
Osteoporosis
Eating disorder
Drug/alcohol abuse (past or current)
Heart palpitations
Ventricular heart problems
Arrhythmia
Pacemaker
IBS
Constipation
Diarrhea
GERD
Heartburn
Pancreatitis
Diverticulitis
Bowel blockage
Other
Other
*
Type of Cancer
*
Food/Medication Allergies?
*
No
Yes
List of Allergies
*
Pregnant or breastfeeding?
No
Yes
Current medications or supplements?
*
No
Yes
Current medications or supplements List
*
Surgical History
*
No surgeries
Yes
Type / Date of Surgery
*
Family Medical History (Check applicable family members only)
Father
Mother
Siblings
Meals/day?
*
1
2
3
More
Snacking?
*
Rarely
Sometimes
Often
Exercise frequency?
*
Never
1–2x/week
3–5x/week
Daily
Sleep/night?
*
<5 hrs
5–6 hrs
7–8 hrs
>8 hrs
Alcohol use?
*
No
Occasionally
Frequently
Drinks / Week
*
Tobacco use?
*
No
Yes
Packs/day
*
Recreational/illicit drug use (past or present)?
*
No
Yes
Type
*
Have you had your cholesterol checked?
*
No
Yes
Date
*
MM slash DD slash YYYY
Result
*
Gynecological History
Have you had a mammogram?
*
No
Yes
Date
*
MM slash DD slash YYYY
Results
*
Have you had a bone density scan?
*
No
Yes
Date
*
MM slash DD slash YYYY
Results
*
Pelvic Exam
*
No
Yes
Date
*
MM slash DD slash YYYY
Results
*
Last Pap Smear
*
No
Yes
Date
*
MM slash DD slash YYYY
Results
*
Abnormal Pap Smear?
*
No
Yes
Treatment
*
Trying to get pregnant?
*
No
Yes
Sexually active?
*
No
Yes
Current birth control method
Problems with it?
How long?
Past birth control & problems
Age of first period
*
Last period
Cycle length
*
Days
Flow
*
Days
Amount of bleeding
*
Normal
Heavy
Light
Other
Other Amount
*
Menstrual Cramp Severity
*
Mid
Moderate
Severe
Duration
Premenstrual symptoms
Start
End
Changes in cycle?
*
No
Yes
Explain
*
Bleeding between periods?
*
No
Yes
When
*
Pelvic pain, pressure, fullness?
*
No
Yes
Describe
*
Vaginal discharge or itching?
*
No
Yes
Describe
*
Treatment?
*
Age at first pregnancy
# of full-term pregnancies
Pregnancy problems?
Miscarriages or abortions?
*
No
Yes
Ovary removal?
*
No
Yes
Ovaries remain?
*
No
Yes
Tubal ligation?
*
No
Yes
When?
*
Hysterectomy?
*
No
Yes
When?
*
General Health Evaluation
Severity – None-0 ____ EXTREME- 10
Sleep Disruptions
*
0
1
2
3
4
5
6
7
8
9
10
Fatigue
*
0
1
2
3
4
5
6
7
8
9
10
Vaginal Dryness
*
0
1
2
3
4
5
6
7
8
9
10
Irritability
*
0
1
2
3
4
5
6
7
8
9
10
Nervousness
*
0
1
2
3
4
5
6
7
8
9
10
Breast Tenderness
*
0
1
2
3
4
5
6
7
8
9
10
Hot Flashes
*
0
1
2
3
4
5
6
7
8
9
10
Dry Skin
*
0
1
2
3
4
5
6
7
8
9
10
Mood Swings
*
0
1
2
3
4
5
6
7
8
9
10
Arthritis
*
0
1
2
3
4
5
6
7
8
9
10
Loss of Recent Memory
*
0
1
2
3
4
5
6
7
8
9
10
Weight Gain
*
0
1
2
3
4
5
6
7
8
9
10
Decreased Sex Drive
*
0
1
2
3
4
5
6
7
8
9
10
Depression
*
0
1
2
3
4
5
6
7
8
9
10
Fluid Retention
*
0
1
2
3
4
5
6
7
8
9
10
Headaches
*
0
1
2
3
4
5
6
7
8
9
10
Night Sweats
*
0
1
2
3
4
5
6
7
8
9
10
Hair Loss
*
0
1
2
3
4
5
6
7
8
9
10
Harder to Reach Climax
*
0
1
2
3
4
5
6
7
8
9
10
Bladder Symptoms
*
0
1
2
3
4
5
6
7
8
9
10
Other
*
0
1
2
3
4
5
6
7
8
9
10
Date of Form Completion
*
MM slash DD slash YYYY
Consent
*
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