EmailMe Form - Patient Intake Form For Women

Patient Intake Form For Women

Thank you in advance for taking the time to fill this out. This information helps me to provide the safest and most effective care for you.

Name *

First Last

Date of Birth *

MM / DD / YYYY

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone Number *

### - ### - ####

Email Address *

Ontario Health Card Number

Relationship status

Occupation

If you are self-employed, please detail your activity so that I can understand what occupation may suggest about your health. Is it sedentary, primarily administrative in nature, or are there any occupational current or prior hazards that might affect your health? Please describe.

	Height (Ft/In)	Weight (Ibs)	Waist Measurement (In)	Last blood pressure, if known
Physical Metrics

When was your last menstrual period?

MM / DD / YYYY

How many full term births have you had?

Have you had any pregnancies, and if yes, how many?

Have you experienced a miscarriage and if yes, how many miscarriages?

Are you currently experiencing regular periods? *

Yes

No

Other (please explain)

What are your plans for your fertility? *

Have you ever experienced the following problems?

Primary Care Provider - Name/Telephone

Other Health Care Providers - Name/Telephone

Allergies

Alcohol Use (past, current, drinks per week)

Smoking
If you smoke please include for how many years? How many packs per day?

What are your current health concerns? *

Please list in priority, note how long you have had these health concerns, what treatments you have tried for these concerns, and the results of the treatments? If you have consulted other healthcare providers for these concerns please include the recommendations and outcome of any treatments advised.

Please note what treatment(s) you are interested in.

Please note your current medical diagnosis, or any current health concerns that you are seeking investigation for. *

Please list any current medications including supplements. *

For each medication please list why you are taking this and how long.

Please describe your current diet. Please describe the diet that you have felt best on in the past, if this is different.

Please describe your digestive health, any reflux, diarrhea, constipation.

Please describe your exercise patterns.

Please describe your sleep and whether you have difficulty falling asleep, staying asleep, or waking up rested.

If you have sleep problems, please advise if you have had a sleep study, the outcome, and what you have tried to help sleep and the outcome.

Please note your past medical history. *

Please describe your family history, include all cancers, cardiovascular disease, blood pressure or cholesterol problems. (For cancers and cardiovascular illness, please note age of person when problem was noted).

Please note any questions you have about BHRT

Please describe your family history, include all cancers, cardiovascular disease, blood pressure or cholesterol problems. With cancers and cardiovascular problems, please note how old person was when problem was noted.

Are you up to date on all recommended cancer screenings? *

Please be advised that NP Melissa does not provide ongoing primary care and that it Is essential for you to remain up to date on recommended screenings, and to promptly report to Melissa any new or concerning symptoms.

I agree to keep my cancer screenings updated and advise NP Melissa of any abnormal findings.

Yes

Women’s Symptom Questionnaire

Please rate each symptom from 0-4
0 none 1 mild 2 moderate 3 severe 4 extremely severe

*

	0 (NONE)	1 (MILD)	2 (MODERATE)	3 (SEVERE)	4 (EXTREMELY SEVERE)
Hot flashes, sweating
Heart discomfort (tightness, skipping, racing)
Sleep problems (difficulty falling asleep, staying asleep, or waking too early)
Depressive mood
Irritability (tension, nervousness, aggression)
Anxiety (restlessness, feeling inner panic)
Physical and mental exhaustion (decreases in performance, impaired memory, decrease in concentration, forgetfulness)
Sexual problems (change in sexual desire, sexual activity and satisfaction)
Bladder problems (difficulty urinating, increased need to urinate, incontinence)
Dryness of vagina, burning, difficulty with sexual intercourse
Joint and muscle discomfort (pain in joints)

If you are seeking treatment for medical weight loss, please advise what strategies you have tried in the past, and how each strategy went for you.

Have you ever thought that you might have binge eating disorder and would you like to be screened for this?

Is there anything else you would like me to know about, in terms of your treatment goals?

Do you consent to communication via text and email? Do you have any concerns regarding communication via text or email or other communication preferences I should be aware of? *

Yes

No

Other Preference

Please send copies of recent labs or relevant diagnostic imaging.