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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
*
Address
City
State
Zip
Email
*
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)
*
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:
Numbness or Tingling
If Yes, where is the numbness or tingling? (If None, type NA)
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
Biote Health History Females (select all that apply)
*
Currently pregnant or trying to conceive
Had a recent mammogram (within last 12 months)
Have had a complete hysterectomy (uterus & ovaries)
Have had a partial hysterectomy (uterus only)
Had menstrual cycle within the last 12 months
Had endometrial ablation?
Am on Birth Control
Am currently partaking in Testosterone therapy
Am currently partaking in Progesterone Therapy
Am currently partaking in Estrogen Therapy
Am partaking in Thyroid Therapy
Am currently on statins
Am a smoker
Am currently on oral nitrates
NONE of the Above
Cardiovascular Conditions: (select all that apply)
*
Heart Attack or Stroke (within 6 months)
Tachycardia
DVT or Blood Clot (within last 6 months)
Hypertension
Hyperlipidemia
Obstructive Sleep Apnea
Atrial Fibrillation
Patient Takes Anticoagulant Medication
NONE of the Above
Gynecological Conditions
*
Pre-Menstrual Syndrome
Endometriosis or History of Endometriosis
Fibrocystic Breast Disease
Fibroids or History of Fibroids
Polyps or History of Endometrial Polyps
NONE of the above
Cancer (female)
*
Breast Cancer or History of Breast Cancer
Endometrial Cancer
Cervical Cancer
Ovarian Cancer
Thyroid Cancer or History of Thyroid Cancer
Except for Basal Cell Carcinoma, Any Other Cancers?
NONE of the Above
Neurological Conditions
*
Epilepsy or Seizure Disorder
Depression/Anxiety
Psychiatric Conditions
Migraine with Aura
Meningioma
NONE of the Above
Endocrine & Metabolic (females)
*
PCOS
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
Organ Specific Conditions (Females)
*
Liver Disease or History of Liver Disease
Kidney Disease or History of Kidney Disease
LAM (Lymphangioleiomyomatosis)
Osteoporosis or Osteopenia
HIV
Hepatitis
Hemochromatosis
Pancreatitis or History of Pancreatitis
History of or Gall Bladder Disease
Polycythemia Vera (PV)
NONE of the above
Female Symptoms & Concerns
*
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
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.
Verification Statement
*
The information provided is accurate & true to the best of my knowledge
Signature
Clear
