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(856) 751-2100
Email:
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Home
Services
Male TRT
Medical Weight Loss
Bio-Identical Hormone Replacement Therapy
Peptide Therapy
Shop
Full Script
Jan Marini
Nutrafol
Patients
New Patient Forms (Female)
New Patient Forms (Male)
Medical Weight Loss Program – Intake Form
About
About Us
Blogs
Reviews
Contact
Request Phone Call
New Patient Form (Females)
Home
New Patient Form (Females)
New Patient (FULL FORMS) - Females
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3
33%
New Patient Demographic Form
Please fill out the required information below. if you have any questions please feel free to call the office at (856) 751-2100.
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
Height
(Required)
Weight
(Required)
Home Address
(Required)
Please input your Street Address
City
(Required)
State
(Required)
Zip Code
(Required)
Home Phone
Cell Phone
(Required)
Work
Email
(Required)
How did you hear about us?
If it's a patients name, please list it below. If other - please write below
In Case of Emergency Contact:
(Required)
Relationship
(Required)
Cell Phone
(Required)
Home Phone
Work
Symptom Checklist
Select EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
1. Hot flashes, sweating
(Required)
(episodes of sweating)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
2. Heart discomfort
(Required)
(unusual awareness of heart beat, heart skipping, heart racing, tightness)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
3. Sleep problems
(Required)
(difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
4. Depressive mood
(Required)
(feeling down, sad, on the verge of tears, lack of drive, mood swings)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
5. Irritability
(Required)
(feeling nervous, inner tension, feeling aggressive)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
6. Anxiety
(Required)
(inner restlessness, feeling panicky)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
7. Physical and mental exhaustion
(Required)
(general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
8. Sexual problems
(Required)
(change in sexual desire, in sexual activity and satisfaction)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
9. Bladder problems
(Required)
(difficulty in urinating, increased need to urinate, bladder incontinence)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
10. Dryness of vagina
(Required)
(sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
11. Joint and muscular discomfort
(Required)
(pain in the joints, rheumatoid complaints)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
Please share any additional comments about your symptoms you would like to address
Do you have cold hands and feet?
(Required)
Yes
No
Do you have daily bowel movements?
(Required)
Yes
No
Do you have gas, bloating, or abdominal pain after eating?
(Required)
Yes
No
Please select your WEEKLY Activity Level based on this criteria
(Required)
Physical activity that accelerates heart rate / Breathlessness
0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days per week (High)
Medical History
Please answer Yes or No or Unsureto the following questions
Medical History (Select All That Apply)
(Required)
High Blood Pressure or Hypertension
Heart Disease
Atrial Fibrillation or other arrhythmia
Blood clot and/or a pulmonary embolism
Depression/anxiety
Chronic liver disease (hepatitis fatty liver cirrhosis)
Arthritis
Hair thinning
Sleep apnea
High Cholesterol
Stroke and/or heart attack
HIV or any type of hepatitis
hemochromatosis
Psychiatrics disorder
Thyroid disease
Diabetes
Lupus or other autoimmune disease
History of breast cancer
Epilepsy or Seizures
Endometriosis or History of Endometriosis
Fibrocystic Breast Disease
PCOS
History of Leiomyoma or Endometrial Polyps
Hashimotos Thyroiditis
Pre-existing Conditions (Select All That Apply)
(Required)
Acne
Breast Tenderness
Facial Hair
Pre-Mentstrual Migraines
Hot Flashes
None
Surgeries (Select All that Apply)
(Required)
Hysterectomy
Ovary removal
Lumpectomy
Mastectomy
None
Screening (Select All that Apply)
(Required)
Mammogram
Papsmear
None
Do you have any Drug Allergies?
(Required)
Yes
No
Drug Allergies
(Required)
If Yes, please explain
Have you ever had any issues with local anesthesia?
(Required)
Yes
No
Do you have a latex allergy?
(Required)
Yes
No
Current Hormone Replacement?
(Required)
Yes
No
If yes, what?
(Required)
Past Hormone Replacement Therapy:
(Required)
If none, write none.
Family History (Select All That Apply)
(Required)
Heart Disease
Diabetes
Osteoporosis
Alzheimer's/Dementia
Breast Cancer
Other
Pertinent Medical/History History (Select All That Apply)
(Required)
Breast Cancer
Uterine Cancer
Ovarian Cancer
Polycystic ovaries/PCOS
Acne
Excess Facial/body hair
Infertility
Endometriosis
Epilepsy or seizures
Fibrocystic breast or breast pain Uterine Fibroids
Irregular or heavy periods Menstrual migraines
Hysterectomy with removal of ovaries
Partial hysterectomy (uterus only)
Oophorectomy removal of ovaries only
Birth Control Method (Select All That Apply)
(Required)
Menopause
Hysterectomy
Tubal ligation
Birth control pills
Vasectomy
IUD
Infertility
Other
Other:
(Required)
Social (Select All That Apply)
(Required)
I am sexually active
I have completed my family
My sex life has suffered
I want to be sexually active
I have NOT completed my family
I have not been able to have an orgasm or it is very difficult
I do not want to be sexually active.
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(856) 751-2100
[email protected]
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Denounce with righteous indignation and dislike men who are beguiled and demoralized by the charms pleasure moment so blinded desire that they cannot foresee the pain and trouble.
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