We acknowledge the commitment you are making to your health and your
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- Alice Gaines
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1 Dear patient, We acknowledge the commitment you are making to your health and your healing. We look forward to our time together. Please fill out the following registration form and questionnaire. We are aware of the sensitivity of several of the questions we ask. If you prefer not to answer any particular question please leave them blank. Payment is expected at the time of service. Phone consultations are available, but there may be a charge depending on the time involved. We do not bill insurance companies. We will work with you as a consultant regarding your hormones as well as with issues related to your overall health. But we are not capable of being your primary care provider. Men need to have a primary care physician. Women need both a primary care physician and a gynecologist, because routine pelvic examinations are required during hormonal therapy. Women may also need a annual mammogram and/or trans-vaginal ultrasound depending upon the situation. If your overall health is reasonable you can expect to begin bioidentical hormone program in the first visit. Getting this program is safe as possible requires frequent follow-up. When you get to an optimal level of hormone replacement the appointments will be more spread out. Name of your primary care provider: Signature
2 Ameri-Cal Weight Clinic Registration Info: Name (Last, First): Date of Birth: Age: Sex: M F Marital Status: Single Married Street Address: City: State, Zip: Home Phone: Cell Phone: May we you information? Current Medications: Medical Allergies: Referred by: Emergency Contact: Reason for visit:
3 Describe any health issues you are having now: Describe any major health issues you have had in the past: Regarding your health, what would you most like to accomplish? Have you had any major operations? Have you been in the hospital for any major illnesses? Do you have any heart problems?
4 Do you have any lung problems? Do you ave any stomach problems? Are there any significant illnesses that run in your family? Describe your current energy level: Describe how well you sleep: Describe your general sense of well-being: Do you have any stress in your life? How is your sex life?
5 For female patients: Do you have any trouble with your breasts including cysts, masses, or breast cancer? When was your last mammogram and what was the result? Do you get regular pelvic examinations? Have you used hormones in the past? Has any woman in your family had breast, uterine or ovarian cancer? What is your current weight? What was your weight when 25 years old? Do you have symptoms of the estrogen deficiency? (Please circle) Hot flashes Night sweats Vaginal dryness Hair lost Depression Weight gain Diminished sexuality Pain with intercourse Do you have symptoms of estrogen excess? (Please circle) Breast tenderness Nipple tenderness Breast fullness Water retention Pelvic cramps
6 Do you have symptoms of progesterone deficiency? (Please circle) Difficulty sleeping Irregular periods Diminished sex drive Anxiety Do you have symptoms of testosterone deficiency? (Please circle) Diminished sex drive Diminished energy Muscle Loss Hair loss Muscle weakness Finding your optimal dose: Too little estrogen can cause: Hot flashes Night sweats Mood swings Sleep disturbance Fogginess & forgetfulness Dry vagina Pain Loss of glowing skin Diminished sexuality Painful intercourse Weight gain especially in the thighs and hips Too much estrogen can cause: Breast tenderness Malaise Breast fullness Nipple tenderness Pelvic cramps with or without bloating Water Retention Too little progesterone: Sleep disturbance Water retention Period irregularities Breast tenderness Anxiety Decreased libido Too much progesterone can cause: Drowsiness Waking up groggy Depressed feeling
7 Too little testosterone can cause: Diminished libido Hair loss Muscular weakness Diminished energy Too much testosterone can cause: Aggressiveness Oily skin Pimples Excessive hair growth
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