Call : (856) 751-2100
Email: [email protected]
Next Level Health at Virapel
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Next Level Health at Virapel
  • Home
  • Services
    • Male TRT
    • 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

Step 1 of 3

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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)
MM slash DD slash YYYY
Please input your Street Address
If it's a patients name, please list it below. If other - please write below

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)
2. Heart discomfort(Required)
(unusual awareness of heart beat, heart skipping, heart racing, tightness)
3. Sleep problems(Required)
(difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
4. Depressive mood(Required)
(feeling down, sad, on the verge of tears, lack of drive, mood swings)
5. Irritability(Required)
(feeling nervous, inner tension, feeling aggressive)
6. Anxiety(Required)
(inner restlessness, feeling panicky)
7. Physical and mental exhaustion(Required)
(general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
8. Sexual problems(Required)
(change in sexual desire, in sexual activity and satisfaction)
9. Bladder problems(Required)
(difficulty in urinating, increased need to urinate, bladder incontinence)
10. Dryness of vagina(Required)
(sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
11. Joint and muscular discomfort(Required)
(pain in the joints, rheumatoid complaints)
Do you have cold hands and feet?(Required)
Do you have daily bowel movements?(Required)
Do you have gas, bloating, or abdominal pain after eating?(Required)
Please select your WEEKLY Activity Level based on this criteria(Required)
Physical activity that accelerates heart rate / Breathlessness

Medical History

Please answer Yes or No or Unsureto the following questions
Medical History (Select All That Apply)(Required)
Pre-existing Conditions (Select All That Apply)(Required)
Surgeries (Select All that Apply)(Required)
Screening (Select All that Apply)(Required)
Do you have any Drug Allergies?(Required)
If Yes, please explain
Have you ever had any issues with local anesthesia?(Required)
Do you have a latex allergy?(Required)
Current Hormone Replacement?(Required)
If none, write none.
Family History (Select All That Apply)(Required)
Pertinent Medical/History History (Select All That Apply)(Required)
Birth Control Method (Select All That Apply)(Required)
Social (Select All That Apply)(Required)
Next Level Health at Virapel

At Next Level Health at Virapel, we're dedicated to helping you achieve your wellness goals with personalized care and cutting-edge treatments.

Hours of Operation

Monday: 9 am - 4 pm
Tuesday: 9 am - 7 pm
Wednesday: 9 am - 5 pm
Thursday: 9 am - 5 pm
Friday - Sunday: Closed

Contact

602 Sheppard Rd, Voorhees
Township, NJ 08043

[email protected]

(856) 751-2100

Website Designed by IL Webdesign

(856) 751-2100
[email protected]
Book Appointment
Next Level Health at Virapel
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