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Female New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. In order to determine if you are a candidate for bio-identical testosterone pellet therapy, we need updated laboratory values and medical history. We will evaluate your information prior to your consultation to determine if BioTE Medical may help you live a healthier life. Please complete the following before your scheduled appointment: 2 weeks or more before your scheduled consultation: Have your blood labs drawn at any lab of your choice or one that is covered by your insurance. If you are not insured or have a high deductible, call our office for self-pay blood draw options. We request the specific lab panels listed below. It is your responsibility to find out if your insurance company will cover the cost. Please note that it may take up to two weeks (10 business days) for your lab results to be received by our office. Your blood work panel MUST include the following tests: Estradiol FSH Testosterone Total TSH T4, Total T3, Free T.P.O. Thyroid Peroxidase CBC Complete Metabolic Panel Vitamin D, 25-Hydroxy (Optional) Vitamin B12 (Optional) Lipid Panel (Optional) (Must be a fasting blood draw to be accurate) Female Post Insertion Labs Needed at 6 weeks. FSH Testosterone Total CBC Lipid Panel (Optional) (Must be a fasting blood draw to be accurate) TSH, T4 Total, T3 Total, TPO (Needed only if you ve been prescribed thyroid medication Estradiol

Female Patient Questionnaire & History Name: (Last) (First) (Middle) Today s Date: Date of Birth: Age: Weight: Occupation: Home Address: City: State: Zip: E-Mail Address: In Case of Emergency Contact: May we contact you via E-Mail? ( ) YES ( ) NO Relationship: Primary Care Physician s Name: Phone: Address: Marital Status (check one): Address City State Zip ( ) Married ( ) Divorced ( ) Widow ( ) Living with Partner ( ) Single In the event we cannot contact you by the mean s you ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment. Spouse s Name: Relationship: Social: ( ) I am sexually active. ( ) I want to be sexually active. ( ) I have completed my family. ( ) My sex has suffered. ( ) I haven t been able to have an orgasm. Habits: ( ) I smoke cigarettes or cigars per day. ( ) I drink alcoholic beverages per week. ( ) I drink more than 10 alcoholic beverages a week. ( ) I use caffeine a day.

Medical History Any known drug allergies: Have you ever had any issues with anesthesia? ( ) Yes ( ) No If yes, please explain: Medications Currently Taking: Current Hormone Replacement Therapy: Past Hormone Replacement Therapy: Nutritional/Vitamin Supplements: Surgeries, list all and when: Last menstrual period (estimate year if unknown): Other Pertinent Information: Preventative Medical Care: ( ) Medical/GYN exam in the last year. ( ) Mammogram in the last 12 months. ( ) Bone density in the last 12 months. ( ) Pelvic ultrasound in the last 12 months. High Risk Past Medical/Surgical History: ( ) Breast cancer. ( ) Uterine cancer. ( ) Ovarian cancer. ( ) Hysterectomy with removal of ovaries. ( ) Hysterectomy only. ( ) Oophorectomy removal of ovaries. Birth Control Method: ( ) Menopause. ( ) Hysterectomy. ( ) Tubal ligation. ( ) Birth control pills. ( ) Vasectomy. ( ) Other: Medical Illnesses: ( ) High blood pressure. ( ) Heart bypass. ( ) High cholesterol. ( ) Hypertension. ( ) Heart disease. ( ) Stroke and/or heart attack. ( ) Blood clot and/or a pulmonary emboli. ( ) Arrhythmia. ( ) Any form of Hepatitis or HIV. ( ) Lupus or other auto immune disease. ( ) Fibromyalgia. ( ) Trouble passing urine or take Flomax or Avodart. ( ) Chronic liver disease (hepatitis, fatty liver, cirrhosis). ( ) Diabetes. ( ) Thyroid disease. ( ) Arthritis. ( ) Depression/anxiety. ( ) Psychiatric disorder. ( ) Cancer (type): Year:

BHRT Checklist For Women Name: Date: E-Mail: Symptom (please check mark) Never Mild Moderate Severe Depressive mood Memory Loss Mental confusion Decreased sex drive/libido Sleep problems Mood changes/irritability Tension Migraine/severe headaches Difficult to climax sexually Bloating Weight gain Breast tenderness Vaginal dryness Hot flashes Night sweats Dry and wrinkled skin Hair falling out Cold all the time Swelling all over the body Joint pain Family History Heart Disease Diabetes Osteoporosis Alzheimer s Disease Breast Cancer NO YES

Hormone Replacement Fee Acknowledgment Although more insurance companies are reimbursing patients for the BioTE Medical Hormone Replacement Therapy, there is no guarantee. You will be responsible for payment in full at the time of your procedure. We will give you paperwork to send to your insurance company to file for reimbursement upon request. New Patient Consult Fee $145 Female Hormone Pellet Insertion Fee $350 Male Hormone Pellet Insertion Fee $725 We accept the following forms of payment: Master Card, Visa, Discover, American Express, Personal Checks and Cash. Print Name Signature Today s Date

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