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FILL FORM COMPLETELY
Mrs.
 Miss
  		Last Name:
 First Name:
Middle:
Address:
 City:
 State:
 Zip:
 Country:
DOB:
 Height:
 Weight:
Home Phone:
 Cell Phone:
 Work Phone:
 E-Mail:
Insurance Company:

 Member ID Number:
 Customer Service Phone Number:
Physician Name:
 Physicians City:
 Physician Phone Number:
Smoker:
  		If yes, how many packs per day? 
Caffeine:
Cups of coffee per day?		 Cans of soda per day?
Exercise:
    
Hysterectomy:
 If yes
Date:      		Reason:
If no, give date of last menstruation: 
 Tubal Ligation:
How many times have you given birth?
 How many times have you had a miscarriage? 
Please list all medications you are currently taking:
Please list any allergies to food or medication:
     
Please list any vitamins or herbal medications you are currently taking:

 

CHECK ALL THAT APPLY

 High Blood Pressure

Ovarian Cysts

Fibrocystic Breast Lumps

Osteoporosis /Osteopenia
If yes, T-score

Cancer  

Fibromyalgia

Diabetes

Low Thyroid

Depression

Elevated Thyroid

Anxiety Disorder

Migraine Headaches

High Cholesterol

Uterine Fibroids Other, Please List
Have you ever taken hormone medications?
 Please list when and for how long you took them.
Do you have a family history of cancer? 
Please list who and what kind of cancer.
Have you ever had an abnormal mammogram? 
Please provide details.
Have you ever had an abnormal Pap Smear?
 Please provide details.
     
Please check the symptoms you are experiencing, please mark each line.
  Severe Moderate Mild None
Hot Flashes
Night Sweats
Vaginal Dryness
Dry Skin
Dry Hair
Weight Gain
Memory Loss
Bladder Infections
Yeast Infections
Difficulty Concentrating
Hair Loss
Irritability
Mood Swings
Breast Tenderness
Nervousness
Anxiety
Headaches
Insomnia
Loss of Sex Drive
Fatigue
Depression
Weak Muscles
Painful Joints
Water Retention

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