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Specialized Therapies:
* Joint Repair
* Hormone Optimization
* Peptides
LIFE ENHANCEMENT CLINICS OF MONTANA
Your Destination for Renewed Vitality!
New Patient Intake Health History Form
Female Patients
First Name
*
Last Name
*
Phone
*
Email
*
Street Address
City
State
Zip
Treatments of Interest (select all that apply)
*
Nervous System Optimization
Regenerative Joint Health Repair
Hormone Optimization
Medical Weight Loss
Preferred Clinic Location:
*
Bozeman
Billings
Helena
Missoula
Today's Date
Birth Date
*
Occupation
How did you hear about us?
Marital Status
Single
Married
Divorced
Living with a Partner
Widow
Emergency Contact name & phone #
providing information here gives us permission to contact concerning your care
Do you currently have active cancer and/or are you currently treating cancer?
*
Yes
No
Tell us more about your cancer/treatment if applicable:
Are you pregnant or trying to get pregnant?
*
YES
NO
What is the #1 health issue you'd like us to address?
*
What have you done to treat the above problems?
Have your symptoms Improved, Stayed the Same or Gotten Worse with treatment?
Improved
Stayed the same
Gotten Worse
What makes your condition Worse?
What makes your condition Better?
Overall Health/Nerve Optimization (click all that apply)
*
Numbness or Tingling
Headaches
Dizziness
Sinus problems
Sciatica/Pinched Nerves
High Stress
Car Accidents
Broken Bones
Work Accidents
Colon problems (constipation/diarrhea)
Heart/circulation issues
Stomach/Reflux
Chronic liver disease (hepatitis, fatty liver, cirrhosis)
Lung problems/Asthma
Thyroid disease
Kidney problems
Liver problems
Rheumatoid Arthritis
Peripheral Neuropathy
Smoker (cigarettes, cigars, e-cigs, marijuana)
Consume Alcohol
Consume Caffeine
NONE of the Above
List any Prescription Drugs you are currently taking:
List any Supplements you are currently taking
List all Allergies:
List all Surgeries that you have had:
JOINT HEALTH
JOINT HEALTH ISSUES (check all that apply)
*
Spine
Neck
Shoulders
Knees
Hips/pelvis
Hands/wrist
Ankle/feet
NONE OF THE ABOVE
REGENERATIVE JOINT HEALTH ISSUES:
Arthritis
Neck Pain
Jaw/TMJ Pain
Mid Back Pain
Scoliosis
Low Back Pain
NONE OF THE ABOVE
Shoulder Pain ?
None
Left
Right
Both
Arm, Elbow, Wrist or Hand Pain ?
None
Left
Right
Both
Hip Problems ?
None
Left
Right
Both
Leg Problems ?
None
Left
Right
Both
Knee Problems ?
None
Left
Right
Both
Foot/Ankle Problems ?
None
Left
Right
Both
Hormone Health
HORMONE Health - Height
*
Current Weight
Goal Weight
Ethnicity
Hot Flashes, sweating (episodes of sweating)
None
Mild
Moderate
Severe
Extremely Severe
Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
None
Mild
Moderate
Severe
Extremely Severe
Sleeping Problems (difficulty in falling asleep, difficulty in sleelping thru the night, waking up early)
None
Mild
Moderate
Severe
Extremely Severe
Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
*
None
Mild
Moderate
Severe
Extremely Severe
Irritability (feeling nervous, inner tension, feeling aggressive)
None
Mild
Moderate
Severe
Extremely Severe
Anxiety
None
Mild
Moderate
Severe
Extremely Severe
Physical & Mental exhaustion
None
Mild
Moderate
Severe
Extremely Severe
Sexual problems (change in desire, sexual activity, satisfaction)
None
Mild
Moderate
Severe
Extremely Severe
Bladder Problems
None
Mild
Moderate
Severe
Extremely Severe
Vaginal Dryness (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
None
Mild
Moderate
Severe
Extremely Severe
Joint & Muscle discomfort (pain in the joints, rheumatoid complaints)
None
Mild
Moderate
Severe
Extremely Severe
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
Yes
No
Do you have gas, bloating or abdominal pain after eating?
Yes
No
Please select your WEEKLY Activity Level based on this criteria: Physical activity that accelerates heart rate / Breathlessness
0-1 days/week (low)
2-3 days/week (average)
More than 3 days/week (high)
Please list any prior hormone therapy?
Female Medical History
Mammogram in last 12 months
Breast Cancer
Hysterectomy with removal of ovaries
Hysterectomy only
Smoker
Adult Acne
Chronic pain medication
ADD medication
Drug allergies
Menstrual Cycle
No (been 12 months since last cycle)
Regular
Irregular
Irregular due to perimenopause
Birth Control Method (females)
Birth Control Pills
IUD
Progestin Shots
Implants
Other:
GLP-1 Contraindications (check all that apply)
Thyroid Tumors
Acute Pancreatitis
Acute Gallbladder
Hypoglycemia
Type 1 Diabetes
Currently taking insulin
Kidney Injuries
Hypersensitivity
Diabetic Retinopathy
Increased Heart Rate
Suicidal Behavior
NONE of the Above
Pregnancy
I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.
By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
Verification Statement
*
The information provided is accurate & true to the best of my knowledge
Signature
Clear
