E.D / Other
New Patient Information
Date of Birth:
What are you looking to address:
Hormone Replacement Therapy
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?
Please list ALL allergies (food, drug, etc.) that you have:
Please list all surgeries with approximate dates:
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:
Do you have difficulty falling asleep?
Do you have difficulty staying asleep?
Do you wake up tired?
Do you snore?
Do you have sleep apnea?
How many hours of sleep do you get a night on average?
(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?
What factors have contributed to your weight gain? (Select all that apply)
What have you tried in the past to lose weight?
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?
Are you currently employed?
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?
If you answered yes, how much and how often?
Have you ever or do you currently use any of the following?
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?
What is a favorite activity or hobby you enjoy doing?
What is your current level of physical activity?
Do you have any barriers that make physical activity difficult?
Have you tried any exercise regiments in the past?
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?
Is there any food that you cannot live without?
Do you drink any of the following?
Do you drink soda?
How many per day?
Do you drink coffee?
How many per day?
At what age did you have your first menstrual cycle?
Have you ever been pregnant?
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?
Do you wake up in the middle of the night to urinate?
Do you have difficulty starting a urine stream?
When was your last prostate exam?