New Patient Form

Background

Name*:

Email*:

Height:

Weight:

Date of Birth:

Medical History:

Males:

Any hormone replacements in the past:

Females: (How regular is your Menstrual Period)

Menopause: (For how long)

Symptoms that might bother you with Menopause:

Any hormone replacements in the past:

Medications & Supplements:

Allergies:

Complaints/Reason for Consultation:

Past Surgical History

Exercise

(How many times a week, and for how long)

Aerobic:

Anerobic:

Food

Vegetables Servings/day:

Fruits Servings/day:

Red Meat Servings/week:

Fish Servings/week:

Snacks Servings/day:

Usual Sources of CHO:

Alcohol: (What kind and how often)

Other Liquids: (How many drinks per day of water, coffee, carbonated, etc.)

Bowel Movements (Issues if any):

Sleep Pattern

Ease of Falling Asleep:

How many times do you wake up at night:

Stress Level:

Memory:

Intimate Relationship & Drive:

Family History: (Hypertension, Diabetes, cancer, strokes, heart attacks, anxiety, depression)

Father:

Mother:

Security Question*:

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