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Patient Information
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Full Name
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DOB
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Biological Sex
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State of Residence (Must be in IA or FL for treatment)
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Primary Goal (Select all that apply)
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Hormone Symptom Checklist
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Please rate the following on a scale of 0 (None) to 5 (Severe)
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Low Energy/Fatigue
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Decreased Libido (Sex Drive)
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Brain Fog / Poor Focus
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Mood Swings / Irritability
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Difficulty Sleeping
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Night Sweats/Hot Flashes
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Weight Gain (Abdominal)
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Joint Pain / Stiffness
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Loss of Muscle Mass
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Anxiety or Depression
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Medical Screening & Safety
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Personal History (Select all that apply)
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Are you currently taking, or have you previously taken, any of the following medications: hormone therapy, blood thinners, or diabetes medications? If yes, please specify the name(s).
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Activity Level
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Alcohol Consumption
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Tobacco/Nicotine Use
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Current Supplements & Vitamins
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Menstrual History
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Are you currently, or do you think you might be pregnant?
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Date of Last Menstrual Period
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Number of Pregnancies
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Number of Miscarriages
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Number of Live Births
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Over the past two weeks, how often have you experienced little interest or pleasure in activities?
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Over the past two weeks, how often have you experienced Feeling down, depressed, or hopeless?
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When was your last mammogram? Were your results abnormal?
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Do you have a history of abnormal mammograms?
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When was your last pap smear? Were your results abnormal?
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Do you have a history of abnormal pap smears?
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Last prostate exam? Were your results abnormal?
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