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Specialized Therapies:
* Joint Repair
* Hormone Optimization
* Medical Weight Loss
New Patient Intake Form
Female Patients
First Name
*
Last Name
*
Phone
*
Email
*
Treatments of Interest
*
Regenerative Joint Repair Therapies
Hormone Optimization (Biote) or Medical Weight Loss
I'm interested in both of the above mentioned therapies
Preferred Clinic Location:
*
Bozeman
Billings
Helena
Missoula
Today's Date
Your Birthday
Address
City
State
Zip
Occupation
How did you hear about us?
Marital Status
Single
Married
Divorced
Living with a Partner
Widow
Emergency/Alternative Contact Info
Emergency/Alternative Contact name:
Contact Phone Number
Number of Children?
Do you currently have active cancer and/or are you currently treating cancer?
Yes
No
Tell us more about your cancer/treatment if applicable:
What health issues/problems are you most concerned about?
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?
What are the top priorities in you life right now?
What activities do you love doing?
Health Issues (click all that apply)
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
Cardiovascular Conditions: (select all that apply)
Heart Attack or Stroke (within 6 months)
DVT or Blood Clot (within last 6 months)
Hypertension
Hyperlipidemia
Obstructive Sleep Apnea
Patient Takes Anticoagulant Medication
Atrial Fibrillation
Tachycardia
NONE of the Above
Neurological/Endocrine/Metabolic (select all that apply)
Epilepsy or Seizure Disorder
Diabetes Type 2 or Insulin Resistance
Hyperthyroid
Hypothyroid
Multiple Endocrine Neoplasia Type-2
NONE of the Above
Autoimmune Conditions (select all that apply)
Diabetes Type 1
Hashimoto’s Thyroiditis
Graves’ Disease
Rheumatoid Arthritis
Multiple Sclerosis
Systemic Lupus (Erthematosus)
Psoriasis
Positive ANA
IBS (Irritable Bowel Syndrome)
Crohn’s Disease
Ulcerative Colitis
NONE of the Above
Blood Pressure Issues ?
High
Low
List all Allergies:
List all Surgeries that you have had:
List any Prescription Drugs you are currently taking:
List any Supplements you are currently taking
JOINT HEALTH ISSUES:
Arthritis
Neck Pain
Jaw/TMJ Pain
Mid Back Pain
Scoliosis
Low Back Pain
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
Numbness or Tingling
If Yes, where is the numbness or tingling? (If None, type NA)
Degeneration ?
If Yes, where is the degeneration? (if None, type NA)
Stiffness ?
If Yes, where are you stiff? (If None, type NA)
Do you Exercise?
Yes
No
How Long & Often do you Exercise?
How healthy do you eat? On a scale of 1-10 (10=awesome, 1=terrible)
Hormone Health
Height:
Current Weight
Goal Weight
Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
Very Severe
Severe
Moderate
Mild
None
Sleep Problems (difficulty falling asleep or sleeping thru the night)
Very Severe
Severe
Moderate
Mild
None
Irritability (mood swings, feeling aggressive or angry)
Very Severe
Severe
Moderate
Mild
None
Anxiety (feeling overwhelmed, panicky or nervous)
Very Severe
Severe
Moderate
Mild
None
Decline in drive or interest (feeling down, sad or loss of "zest for life")
Very Severe
Severe
Moderate
Mild
None
Depression
Very Severe
Severe
Moderate
Mild
None
Joint and Muscular Symptoms (poor recovery after workout, inability to add muscle, joint pain, muscle weakness)
Very Severe
Severe
Moderate
Mild
None
Difficulties with memory (concentration, finding the right word, or retaining information)
Very Severe
Severe
Moderate
Mild
None
Sexual Desire or Performance (reduced or diminished)
Very Severe
Severe
Moderate
Mild
None
Vaginal dryness or difficulty with sexual intercourse
Very Severe
Severe
Moderate
Mild
None
Difficulty or Inability to Orgasm
Severe
Moderate
Mild
None
Hot Flashes
Very Severe
Severe
Moderate
Mild
None
Sweating (night sweats or increased episodes of sweating)
Very Severe
Severe
Moderate
Mild
None
Hair loss, thinning, or change in texture of hair
Very Severe
Severe
Moderate
Mild
None
Feeling cold all the time, having cold hands or feet
Very Severe
Severe
Moderate
Mild
None
Headaches or Migraines
Very Severe
Severe
Moderate
Mild
None
Weight (difficulty losing weight despite diet/exercise)
Very Severe
Severe
Moderate
Mild
None
Bladder problems (difficulty in urinating, increased need to urinate)
Very Severe
Severe
Moderate
Mild
None
Acne
Severe
Moderate
Mild
None
Biote Health History Females (select all that apply)
Blood clot, DVT, heart attack or stroke since being pelleted?
Have you been diagnosed with any cancer since initial pelleting (excluding basal cell carcinoma)?
Currently pregnant or trying to conceive
Had a recent mammogram (within last 12 months)
Had menstrual cycle within the last 12 months
Had endometrial ablation
Am on Birth Control
Have had a hysterectomy
Am currently utilizing BHRT or HRT
Am currently on statins
currently on oral nitrates
PCOS/Polycystic ovaries
Pre-Menstrual Syndrome
Endometriosis or History of Endometriosis
Fibrocystic Breast Disease
Fibroids or History of Fibroids
Uterine Fibroids
Breast Tenderness/Fibrocystic breasts
Polyps or History of Endometrial Polyps
Painful Intercourse
Infertility
Breast, Uterine or Ovarian Cancer
Breast tenderness
Dry or flaking skin
Frequent urinary tract infections
Brittle nails
Mind racing at bedtime
Facial hair
Dry eyes
Eating when stressed
NONE of the Above
Semaglutide 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
Other symptoms or unique health circumstances to take into consideration
The first day of my last menstrual cycle was on ?
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.
Signature
Clear
