Medical History
Hormone Optimization Consultation -Female
NAME:_____________________________________________DATE:_______________
CELL PHONE:______________________________HOME PHONE:_______________________
ADDRESS:___________________________________CITY____________________STATE_____
ZIP_________________
D.O.B.:___________________________
EMAIL ADDRESS:______________________________ CAN WE SEND EMAILS: YES NO
Physician_____________________________________________________________________
PLEASE LIST THE FOLLOWING:
ALLERGIES:____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CURRENT MEDICATIONS- PRESCRIPTION & NONPRESCRIPTION( name/dose/ reason for
taking):_______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CURRENT SUPPLEMENTS (name & dose):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HOSPITAL ADMISSIONS/SURGERIES (not including pregnancies):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Medical History
Enter “X” & indicate age & dates for all questions which have ever applied to you. Enter “C”
for current ongoing problems, details & dates.
Ringing in ear
Dizzy Spells
Abdominal Pain- Chronic
Have bowel movement every___day(s)
Fainting Spells
Failing Vision
Eye Pain
Hoarseness- prolonged
Hay Fever/Allergies
Frequent: [ ] Constipation
[ ] Diarrhea
Urination- Overactive Bladder
Overnight less than twice
More than 8 times/24 hrs
Urgency to urinate
Shortness of Breath:
On exertion
Laying flat
Chest Pain
High Blood Pressure
Heart Murmur
Decrease in urinary force/flow
Painful urination
Stress incontinence-urine leakage
Recent weight- [ ] Gain [ ] Loss: ________lbs
Anemia
Bruise Easily
Swollen Ankles
Irregular Pulse
Palpitations
Leg Pain- when walking
Varicose Veins/Phlebitis
Chronic Fatigue
Diabetes
Thyroid Disease
Numbness/tingling sensations
Headaches- frequent
Cold Numb Feet
Loss Appetite- Recent
Difficulty Swallowing
Heartburn
Bone Fracture/Joint Injury
Arthritis: type/location
------Social History----[ ] Coffee_________ [ ] Tea________cups/day
Alcohol # of drinks a day_____
A week_______
Fractures after 50? [ ]Yes [
]No
Joint Pain
Location:
Rashes
Hives
Psoriasis
Smoking:_________cigarettes/day?__________#years
Recreational drugs:
Eczema
Females (Please complete the following)
Age of onset of menstrual periods______
Pregnancies:
If Menopausal, date of last
period________________________
Date of 1st Day of last
period________________________
Abortions:
# of days of flow________________
Length of cycle_________________
Periods: [ ] Regular [ ] Irregular
[ ] Pain/Cramps
Pain/Bleeding during or after sex
Live Births:
Miscarriages:
Did you ever breast feed [ ] YES [ ] NO
At Least 1 yr. collectively [ ]YES [ ] NO
Birth Control Method:
Postpartum Depression [ ]YES [ ]NO
Check Symptoms you currently experience:
Mental Fogginess
Forgetfulness
Depression
Minor Anxiety
Mood Change
Difficulty falling asleep
Hot Flashes
Night Sweats
Temperature Swings
Increase of breast size
Water retention
Impatient snappy behavior
Pelvic Cramps
Nausea
Flabbiness and muscular weakness
Loss of hair
Lack of energy and stamina
Time of day when loss of
stamina______________
Loss of coordination and balance
Decrease sex drive
Decreased Hair- armpit, pubic, body
Harder to reach climax
Hard to concentrate
Day-long fatigue
Decrease sense of sexuality
Lessened self-image
Dry eyes, skin and vagina
Sagging breast & loss of fullness
Pain with sexual activity
How do/did you feel during different days in the monthly fluctuations of your cycle?
_____________________________________________________________________________________
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How do/did you feeling a few days before your period?
_____________________________________________________________________________________
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How did/do you feel from the day of ovulation to the onset of heavy flow?
_____________________________________________________________________________________
_____________________________________________________________________________________
If on birth control how did symptoms change after starting?
_____________________________________________________________________________________
_____________________________________________________________________________________
SCREENING TESTS
SCREEN
DATE
ABNORMAL?
Cholesterol/Lipids
SCREEN
DATE
ABNORMAL?
Dental Exam
Eye Exam
Skin Exam
Rectal/Colonoscopy
PSA (prostate test)
Prostate Exam
Blood Sugar
Pap Smear
Mammogram
Bone Density
Vascular
UItrasound
IF A BLOOD RELATIVE HAS SUFFERED ANY OF THE FOLLOWING-PLEASE CIRCLE THE NUMBER
AND INDICATE WHICH RELATIVE(S). PROVIDE ADDITIONAL DETAILS
1. ANEMIA
6. ALCOHOLISM
2. ASTHMA
3. EPILEPSY
4. HEPATITIS
7. BLEEDS EASILY
8. GLAUCOMA
9. HYPERTENSION
5. OSTEOPOROSIS
10. STROKE
11. ALZHEIMER’S
DX
12. CANCER (TYPE)
13. HAY FEVER
14. LIPID DISORDER
15. THYROID
DISEASE
16. ARTHRITIS
17. DIABETES
18. HEART DISEASE
19. MENTAL
ILLNESS
20. HIP FRACTURE
AFTER AGE 50
DETAILS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Exercises
Current Sources of Stress
My Primary Health Concerns
List any diets you have been on during the past 12 months, along with the reason(s) for
following it, the benefits or problems you experienced with it, and the reason(s) for stopping
any diet.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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CONSENT TO FILE INSURANCE/FINANCIAL RESPONSIBILITY
Your medical health coverage is a contract between you and your insurance company. ReGeneration,
P.C. will file in Network medical insurance claims. In network insurance company co-payments and
deductibles are due at time of service. Our facility insurance claims are serviced by Medical Billing
Associates.
Patients with out of Network insurance are responsible for payment in full at time of service.
A Billing statement will be prepared for you to file with your insurance company.
By my signature below, I give my consent to ReGeneration, P.C. to file a medical claim to my carrier. I
understand that all unpaid charges are my responsibility. If you have any questions please feel free to
ask.
Printed Name_________________________________________________________
Signature of patient or legal guardian_______________________________________________
Date:___________________________________
A 24 hour notice of cancellation is required. If your cancellation is less than 24 hours or you do not show for your appointment a
rescheduling fee will apply before for your next appointment. This is for the consideration of our patients that are waiting for an
earlier appointment and allows us the necessary time to contact them with appointment availability. We thank you for understanding
regarding this policy that has proven to be very successful in meeting our patents needs.
Patient Signature_________________________________________
Date________________