Home
About
Medical Team
Contact Us
Online Forms
Post Treatment Guides
Specialized Therapies:
* Joint Repair
* Hormone Optimization
* Medical Weight Loss
LIFE ENHANCEMENT CLINICS OF MONTANA
Your Destination for Renewed Vitality!
Health History & Symptoms Form
Female Patients
First Name
Last Name
Today's Date
Date of birth
Age
Height:
Current Weight
Have you been diagnosed with any cancer since initial pelleting? (excluding basal cell carcinoma)?
YES
NO
No elements found. Consider changing the search query.
List is empty.
Blood Clot, DVT, heart attack or stroke since initial pelleting and/or last visit?
YES
NO
No elements found. Consider changing the search query.
List is empty.
Any changes in medical conditions since initial pelleting and/or last visit?
Any changes in medications since initial pelleting and/or last visit?
Biote Female Health History + Symptoms (Continuous Maintenance)
Hot Flashes
Night Sweats
Vaginal Dryness
Decreased Interest is Sex
Inability To Achieve or Delayed Orgasm
Painful Intercourse
Urinary Incontinence
Frequent Urinary Tract Infection
Breast Tenderness
Weight Gain
Hair Loss
Hair Thinning
Thinning Eyebrows
Cold Hands or Feet
Brittle Nails
Dry or Flaking Skin
Lack of Energy (Fatique)
Decreased Muscle Mass
Acne
Facial Hair
Dry Eyes
Joint Pain
Difficulty Sleeping
Mind Racing at Bedtime
Eating When Stressed
Verification Statement
*
The above information is true to the best of my knowledge.
Patient Signature
*
Clear
