New Patient Forms (Females)

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)

Race(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

Preferred Pharmacy(Required)

Please input the name of your Preferred Pharmacy to receive medications

City(Required)

State(Required)

Zip Code(Required)

Pharmacy Phone Number(Required)

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

Do you have daily bowel movements?(Required)

Yes

Do you have gas, bloating, or abdominal pain after eating?(Required)

Yes

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

None

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

Date Of Screening(Required)

MM slash DD slash YYYY

Current Medications(Required)

Please list any and all medications that you are currently taking. If none, write NONE.

Drug Allergies(Required)

If Yes, please explain

Date Of Last Menstrual Period

Please write the date

Have you ever had any issues with local anesthesia?(Required)

Yes

Do you have a latex allergy?(Required)

Yes

Current Hormone Replacement?(Required)

Yes

Do You Smoke?(Required)

Yes

If you answered Yes to the question above, please specify how many cigarettes you smoke per day.

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

None

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

None

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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