LUCKAYDOC

Tel: 540-777-6807

New Patient Information

Name:

Phone:

Email:

Street Address:

City:

State:

Zip:

Today's Date:

Date of Birth:

Primary Insurance:

Member ID:

Secondary Insurance:

Member ID:

What are you looking to address: Hormone Replacement Therapy
Weight Loss
Both

Comments:

MEDICAL HISTORY

Do you currently have or have ever been diagnosed with any medical condition(s)? If so, please list them below:

Have you ever been treated by a healthcare professional for anxiety, depression, or any other mental health issues?
Yes No

Please list ALL allergies (food, drug, etc.) that you have:

SURGICAL HISTORY

Please list all surgeries with approximate dates:

MEDICATIONS

Please list all medications you are currently taking:

Please list all supplement and/or vitamins you are currently taking:

Please list any current hormone replacement regimes:

Please list any past hormone replacement regimes:

SLEEP HISTORY

Do you have difficulty falling asleep?
Yes No

Do you have difficulty staying asleep?
Yes No

Do you wake up tired?
Yes No

Do you snore?
Yes No

Do you have sleep apnea?
Yes No

How many hours of sleep do you get a night on average?

WEIGHT HISTORY

(If you are not concerned about your weight, you may skip this section.)

At what age did you begin to gain weight?

How would you say your weight gain progressed?
Slowly Rapidly

What factors have contributed to your weight gain? (Select all that apply)
Stress Marriage Divorce Illness Medication Abuse Trauma Others:

What have you tried in the past to lose weight?
Commercial Programs Popular/Fad Diets Physician Directed

What has worked best for you?

What did you like and dislike?

What hasn’t worked for you, and why?

Have you ever used any prescribed or over the counter diet medications? If so what and when?

Have you even been diagnosed and treated by a healthcare professional for any type of eating disorder, such as bulimia, anorexia nervosa, binge eating, or night eating syndrome? Yes No
Explain

SOCIAL HISTORY

Are you currently employed?
Yes No

If you answered yes, what is your occupation?

Do you get up and move around or sit most of the time while working?

Do you drink alcohol?
Yes No

If you answered yes, how much and how often?

Have you ever or do you currently use any of the following?
Cigarettes Dip/Chew Vape

How long have you or did you use nicotine products?

What is your relationship status?

Describe your living situation, i.e., alone, significant other, roommate, parents.

What are some current major stressors in your life?

Have you ever been in an abusive relationship? Yes No
Explain

What is a favorite activity or hobby you enjoy doing?

EXERCISE HISTORY

What is your current level of physical activity? Sedentary Moderate Active

Do you have any barriers that make physical activity difficult?

Have you tried any exercise regiments in the past? Yes No

DIETARY HISTORY

How would you describe your eating habits?
Eat at defined times Graze throughout the day Eat one meal a day

At what time(s) of the day do you eat?

What are your eating triggers?
People Places Activities Stress Boredom Emotional

Is there any food that you cannot live without?

Do you drink any of the following?

Do you drink soda? Yes No How many per day?

Do you drink coffee? Yes No How many per day?

Regular Diet Caffeinated Decaffeinated

WOMAN ONLY

At what age did you have your first menstrual cycle?

Have you ever been pregnant?
Yes No

If you answered yes to being pregnant were there any complications?

When was your last menstrual cycle?

When was your last pap smear?

What is your current birth control method?

Do you have a history of any of the following?
Abnormal Pap PCOS Fibrocystic breast Hair Loss Uterine Fibroids Facial Hair

MAN ONLY

Do you wake up in the middle of the night to urinate?
Yes No

Do you have difficulty starting a urine stream?
Yes No

When was your last prostate exam?