FEMALE HORMONE INTAKE FORMS

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Client First and Last Name: Nickname: “”
Address, City, State, Zip: Email:
Telephone
Home:000-000-0000 Cell:000-000-0000 Work:000-000-0000 Ext: / Driver License Number
How would you prefer us to communicate with you regarding appointments, treatments or program information? Check all that apply.
Email: Text Messaging*: Cell Phone: Work Phone: Home Phone:
*Our text messaging system requires your cell phone carrier name:
May we contact you via email and/or text not more than once every 60 days with special offers? YES NO
Height: 0’ 00” Current Weight: 000 LBS Weight 1 Year Ago: 000 LBS / BP if Known: 000/00 w/ meds w/o meds
Birth date: 00/00/0000 Age: 00 Gender: FEMALE MALE
Emergency Contact: Contact #: 000-000-0000 Relationship:
Referred by:
Sign/Drive-by AMOWC.COM Friend/Family Facebook, LinkedIn, Twitter Other:
FAMILY OR FRIEND’S NAME WHO REFERRED YOU:
Status:
Single Married Divorced Widowed Domestic Partnership
Employment:
Full Time Part time Retired Not employed Student
Primary Physician: Phone: 000-000-0000 Fax: 000-000-0000
Physician Address: Date of Last Visit: 00/00/0000
Reason for Today’s Visit:

IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING: I certify that I am a competent adult of at least 18 years of age. Should there be an early termination of services for any reason, any amount determined to be due will be refunded within 90 days. All documents, reports, and verbal or written information received from AMOWC is sensitive and confidential Proprietary Information provided to the Client for personal use only. By signing or inserting your typed name below, I agree not to, directly or indirectly, publish, disclose or otherwise disseminate such information without prior written approval by AMOWC during or after my treatment. FURTHER, I UNDERSTAND A COMPLIMENTARY CONSULTATION IS PROVIDED BY THE PHYSICIAN’S APPOINTED NON-MEDICAL REPRESENTATIVE AND IS STRICTLY TO PROVIDE PROGRAM/TREATMENT INFORMATION. ANY DIAGNOSIS AND/OR TREATMENT MUST BE MADE BY THE LICENSED PHYSICIAN DURING THE PHYSICIAN FACE-TO-FACE CONSULTATION. I certify that I have read and fully understand the contents.

00/00/0000

______

Client Typed Signature Date Signature

Last Updated: 12/9/201 12:48 PMPage 1

MEDICAL HISTORY

Are you presently being treated for a medical condition? Yes No
If yes, please describe:
What health issues would you like to address?
What medical or treatment therapies are you currently receiving?
Are there any health concerns or information we should know about you?
List any major hospitalizations, operations or illness:
0000 Year 0000 Year 0000 Year

FAMILY HISTORY INFORMATION - Please check all that apply

CHILD / BROTHER / SISTER / FATHER / MOTHER / SELF /

DISEASES / DISORDERS

/

PHYSICANS NOTES

Abnormal Blood Pressure
Anxiety
Arthritis or Joint Problems
Autoimmune Disease
Blood Disorders/Anemia
Breast Cancer
Cancer/Tumors/Cysts
Depression/Mental Illness
Diabetes
Drug/Alcohol Abuse
Eczema
Endocrine or Thyroid
Epilepsy
Excessive Bleeding
Eye Disease
Fibrocystic Breast
Headaches/Migraines
Heart Disease
Herpes/Cold Sores
High Cholesterol/Lipids
HIV/Aids/Hepatitis/HPV
Hormone Issues
Jaundice/Liver Disease
Keloid Scarring
Kidney or Bladder
Lung Condition
Melanoma/Skin Cancer
Osteoporosis
Ovarian Cancer
Phlebitis/Varicose Veins
Pneumonia
PCOS
Rheumatic Fever
Rheumatoid Arthritis
Thyroid Disease
Tuberculosis
Seizures
Stroke
Ulcers

MEDICATIONS – VITAMINS – SUPPLEMENTS – ALLERGIES

List current Rx medications:
List current over the counter medications:
List current minerals, herbs, vitamins, supplements:
Do you have any drug allergies: No Yes
If yes, please list:
Do you have environment and/or diet allergies: No Yes
If yes, please list:

HABITS

Coffee / No Yes / Quantity per day or per week
Tobacco / No Yes / Quantity per day or per week
Alcohol / NoYes / Quantity per day or per week

SYSTEMS REVIEW – Check all that apply

Abdomen Pain / Leg Cramps
Back Pain / Loss of appetite
Blood/ Pus in urine / Nausea/Vomiting
Bloody Stool/Hemorrhoids / Neck goiter
Bowel Habit Changes / Neck Swelling/Lump
Chronic Cough / Night Sweats
Constipation / Palpitations/Flutters
Coughing Blood / Seeing Double
Ear Infections / Shortness of Breath
Earache/Discharge / Skin Trouble
Ears Ringing / Sore Throats
Fatigue / Swollen Ankles
Headaches/Dizziness / Weakness

FEMALE HORMONE EVALUATION

ClientFirst & Last Name:
Number of: Total Pregnancies Living Ectopic Miscarriages Abortions
Have you ever used oral contraceptives? Yes No Began at what age? Age stopped?
Any problems?
Have you had a hysterectomy? Yes No Ovaries Removed? Yes No Tubal ligation? Yes No
What was the reason for your hysterectomy?
Date of surgery:
Have you had cancer? Yes No
When: Type: Receptor + or - : Grade & Treatment: Stage:
Have you had these tests performed?
PAPS Smear: Yes No Year: Mammogram: Yes No Year:
Date of last period: Are your menstrual cycles: 21-day 28-day 35-day Irregular
When is your normal bedtime? Waking time? How many hours do you average nightly?
Do you have trouble falling asleep?
Do you wake up in the middle of the night? Yes No How many times?
Have you previously taken hormones? Yes No
If yes, what? Date Started: Date Stopped:
Have you previously taken growth hormone? Yes No
If yes, what? Date Started: Date Stopped:
What are your current primary symptoms?
GYN Physician Name: Phone: 000-000-0000

Check all that apply

PAST / PRESENT / CONDITION / PAST /

PRESENT

/ CONDITION
Abnormal Bleeding / Other:
Breast Lumps
Irregular Menstrual Periods
Menopausal Symptoms
Painful Menstrual Periods
Premenstrual Syndrome

FEMALE HORMONAL SYMPTOMS – Check all that apply in each category

Anxiety / Absent / Mild / Moderate / Severe
Allergies / Absent / Mild / Moderate / Severe
Brain Fog / Absent / Mild / Moderate / Severe
Breast pain or tenderness / Absent / Mild / Moderate / Severe
Bloating / Absent / Mild / Moderate / Severe
Body odor / Absent / Mild / Moderate / Severe
Bone loss / Absent / Mild / Moderate / Severe
Burning tongue / Absent / Mild / Moderate / Severe
Chronic fatigue / Absent / Mild / Moderate / Severe
Gum bleeding / Absent / Mild / Moderate / Severe
Depression / Absent / Mild / Moderate / Severe
Difficulty concentrating / Absent / Mild / Moderate / Severe
Discomfort during sex / Absent / Mild / Moderate / Severe
Disorientation and dizziness / Absent / Mild / Moderate / Severe
Dry eyes / Absent / Mild / Moderate / Severe
Dry itchy skin / Absent / Mild / Moderate / Severe
Emotional bouts / Absent / Mild / Moderate / Severe
Facial hair increase / Absent / Mild / Moderate / Severe
Face flushing / Absent / Mild / Moderate / Severe
Fingernails and/or hair, dry, brittle / Absent / Mild / Moderate / Severe
Feelings of apprehension doom and gloom / Absent / Mild / Moderate / Severe
Forgetfulness / Absent / Mild / Moderate / Severe
Hair loss / Absent / Mild / Moderate / Severe
Headaches / Absent / Mild / Moderate / Severe
Hot flashes / Absent / Mild / Moderate / Severe
Increased need to urinate / Absent / Mild / Moderate / Severe
Irregular periods / Absent / Mild / Moderate / Severe
Joint and/or back pain / Absent / Mild / Moderate / Severe
Lethargy and tiredness / Absent / Mild / Moderate / Severe
Light headedness / Absent / Mild / Moderate / Severe
Loss of balance / Absent / Mild / Moderate / Severe
Loss of libido / Absent / Mild / Moderate / Severe
Memory lapse / Absent / Mild / Moderate / Severe
Menstrual irregularities / Absent / Mild / Moderate / Severe
Mental confusion / Absent / Mild / Moderate / Severe
Migraines / Absent / Mild / Moderate / Severe
Moodiness / Absent / Mild / Moderate / Severe
Muscle aches and pains / Absent / Mild / Moderate / Severe
Night sweats / Absent / Mild / Moderate / Severe
Osteoporosis / Absent / Mild / Moderate / Severe
Panic disorder / Absent / Mild / Moderate / Severe
Rapid heartbeat / Absent / Mild / Moderate / Severe
Inability to sleep and/or night time awakenings / Absent / Mild / Moderate / Severe
Sudden tears / Absent / Mild / Moderate / Severe
Thinning hair / Absent / Mild / Moderate / Severe
Tingling extremities / Absent / Mild / Moderate / Severe
Urinary urges / Absent / Mild / Moderate / Severe
Vaginal dryness / Absent / Mild / Moderate / Severe
Weight gain and/or increased belly fat / Absent / Mild / Moderate / Severe
Symptoms of cortisol and adrenal imbalance
HC
Extreme fatigue / Absent / Mild / Moderate / Severe
Weak muscles / Absent / Mild / Moderate / Severe
High blood pressure / Absent / Mild / Moderate / Severe
High blood sugar / Absent / Mild / Moderate / Severe
Increased thirst / Absent / Mild / Moderate / Severe
Frequent urination / Absent / Mild / Moderate / Severe
Irritability / Absent / Mild / Moderate / Severe
Upper body obesity / Absent / Mild / Moderate / Severe
Thin skin / Absent / Mild / Moderate / Severe
Stretch marks / Absent / Mild / Moderate / Severe
Bruises easily / Absent / Mild / Moderate / Severe
AD/CD
Persistent anxiety / Absent / Mild / Moderate / Severe
Always on the go – high-adrenaline lifestyle / Absent / Mild / Moderate / Severe
Difficulty getting to sleep / Absent / Mild / Moderate / Severe
Difficulty staying asleep / Absent / Mild / Moderate / Severe
Feeling tired but wired / Absent / Mild / Moderate / Severe
Abdominal weight gain / Absent / Mild / Moderate / Severe
Panic attacks / Absent / Mild / Moderate / Severe
Easily fly off the handle / Absent / Mild / Moderate / Severe
LC
Chronic worsening fatigue / Absent / Mild / Moderate / Severe
Weak muscles / Absent / Mild / Moderate / Severe
Loss of appetite / Absent / Mild / Moderate / Severe
Weight loss / Absent / Mild / Moderate / Severe
Abdominal pain, nausea, vomiting, diarrhea / Absent / Mild / Moderate / Severe
Low blood pressure / Absent / Mild / Moderate / Severe
Salt cravings / Absent / Mild / Moderate / Severe
Patches of dark skin (scars, skin folds, elbows, knees) / Absent / Mild / Moderate / Severe
AF
Difficulty waking in morning / Absent / Mild / Moderate / Severe
Feeling unrefreshed after sleep / Absent / Mild / Moderate / Severe
Ongoing fatigue, unrelieved by sleep / Absent / Mild / Moderate / Severe
Lack of energy, lethargy, weariness / Absent / Mild / Moderate / Severe
Lightheadedness / Absent / Mild / Moderate / Severe
Increased salt cravings / Absent / Mild / Moderate / Severe
Low libido / Absent / Mild / Moderate / Severe
Inability to handle stress / Absent / Mild / Moderate / Severe
Feeling overwhelmed / Absent / Mild / Moderate / Severe
Mild depression / Absent / Mild / Moderate / Severe
Mental fogginess/fuzzy thinking / Absent / Mild / Moderate / Severe
Frequent infections / Absent / Mild / Moderate / Severe
Increased energy after evening meal / Absent / Mild / Moderate / Severe
Longer recovery times from illness, injury or trauma / Absent / Mild / Moderate / Severe
Symptoms of low thyroid function
Allergies / Absent / Mild / Moderate / Severe
Brittle hair and nails / Absent / Mild / Moderate / Severe
Cold hands and feet / Absent / Mild / Moderate / Severe
Cold temperature intolerance / Absent / Mild / Moderate / Severe
Constipation / Absent / Mild / Moderate / Severe
Decreased sweating / Absent / Mild / Moderate / Severe
Depression / Absent / Mild / Moderate / Severe
Dry skin / Absent / Mild / Moderate / Severe
Goiter / Absent / Mild / Moderate / Severe
Heart palpitations / Absent / Mild / Moderate / Severe
Hoarseness / Absent / Mild / Moderate / Severe
Inability to lose weight / Absent / Mild / Moderate / Severe
Infertility problems / Absent / Mild / Moderate / Severe
Low libido / Absent / Mild / Moderate / Severe
Menstrual irregularities / Absent / Mild / Moderate / Severe
Nails breaking or brittle / Absent / Mild / Moderate / Severe
Rapid heartbeat / Absent / Mild / Moderate / Severe
Shortness of breath / Absent / Mild / Moderate / Severe
Slow pulse rate / Absent / Mild / Moderate / Severe
Sluggishness / Absent / Mild / Moderate / Severe
Weight gain / Absent / Mild / Moderate / Severe
Symptoms of high thyroid function
Diarrhea / Absent / Mild / Moderate / Severe
Eye/vision changes / Absent / Mild / Moderate / Severe
Hair loss / Absent / Mild / Moderate / Severe
Insomnia / Absent / Mild / Moderate / Severe
Palpitations / Absent / Mild / Moderate / Severe
Rapid heart beat / Absent / Mild / Moderate / Severe
Sweating / Absent / Mild / Moderate / Severe
Weakness / Absent / Mild / Moderate / Severe
Weight loss / Absent / Mild / Moderate / Severe
Symptoms of insulin imbalance
Increased abdominal fat / Absent / Mild / Moderate / Severe
Increased hunger / sugar cravings / Absent / Mild / Moderate / Severe
Low/high blood sugar / Absent / Mild / Moderate / Severe
Poor circulation to extremities / Absent / Mild / Moderate / Severe
Skin changes / Absent / Mild / Moderate / Severe
Symptoms of adult growth hormone deficiency
Abnormal blood cholesterol / Absent / Mild / Moderate / Severe
Decreased muscle mass / Absent / Mild / Moderate / Severe
Decreased stamina and exercise ability / Absent / Mild / Moderate / Severe
Increased abdominal fat / Absent / Mild / Moderate / Severe
Pain, Energy, Stress
Is your current level of back/joint pain / Absent / Mild / Moderate / Severe
Is your energy level in the morning / Low / Normal / High
Is your energy level in the late afternoon / Low / Normal / High
Is your stress level the past 30 days / Low / Normal / High
Is your stress level the past 6 – 12 months / Low / Normal / High

WEIGHT LOSS PROGRAM QUESTIONNAIRE

COMPLETE ONLY IF YOU ARE 15 POUNDS OR MORE OVERWEIGHT

What is your Ideal Weight:LBS What is yourGoal Weight:LBS How many pounds do you want to lose?

Do you want to lose 1, 2, 3 or 4+ lbs per week? LBSOver what period of time?WEEKS

What is the heaviest you’ve been? LBS What is the most weight you’ve lost? LBS

Have you maintained any weight loss of 10 or more pounds for up to 1 year or longer? Yes No

If not, what caused the weight gain?

Have you ever joined a weight loss program before? Yes No

If yes, what did you learn from these programs? What did not work about these programs?

What is your biggest struggle with maintaining your ideal weight?

Are your family/friends a good support team for you? Yes NoAre you easily motivated? Yes No

What would be the most helpful in assisting you with weight loss?

Check any of the dietary problem areas listed below that apply to you:

Skip MealsEat out too often Large or Multiple Servings

Drink 2+ times a week Eat fried/fatty foods Frequent Snacking

Crave Carbs*Eatafter 8 PM Eat when not hungry

Eat sweets: candy, cookies, etcEat breads, pastasEat potatoes, white rice

*i.e.:candy, cakes, pies, pastries, breads, pastas, potatoes, rice

How often do you eat out each week? Breakfast Lunch Dinner

How often are those meals fast food (i.e. McDonalds, Wendy’s, Chick-fil-A)?Breakfast Lunch Dinner

Do you cook meals for yourself/family? Yes NoCan you prepare meals in advance? Yes No

Can you remove junk food from your home? Yes NoDo you travel a lot? Yes No

Do you drink alcohol, beer or wine? Yes NoDo you drink diet sodas? Yes No

Do you use box/packaged meals? Yes NoDo you microwave foods? Yes No

Do you read ingredients on labels? Yes No

How many 8 oz glasses of water do you drink per day?

Do you know the difference between?

Healthy/Unhealthy Fats Yes No Complex/Simple/Fibrous Carbohydrates Yes No

Weight Loss/Fat Loss Yes No

Do you exercise? Yes NoIf yes, how often per week: 1-2 3-4 5+ Week

If no, would you consider some form of exercise to help you reach your goal weight? Yes No

Do you belong to a gym? Yes No

IN-OFFICE USE ONLY

1 / 2 / 3 / 4 / Initial Handouts Provided STARTING BMR: ( )
LGHT
MOD
AGG
S-AGG / SIM
MOD
DIF
EXT / SIM
MOD
DIF
EXT / SIM
MOD
DIF
EXT / 1.
2.
3.
4.

FEMALE CONSENT FOR BIO-MIMETIC HORMONE RESTORATION & NUTRITIONAL THERAPY

After reading each below statement, please type your initials in each grey square box.

I hereby request and consent to the administration of bio-mimetic hormones and/or nutritional supplements by AMOWCfor the purpose of restoring optimal levels — even when laboratory test results are within reference ranges for age and/or in circumstances where various professional medical organizations do not recommend supplementation.

I will consult my primary care physician and/or endocrinologist (medical physician) and encourage/facilitate inter-physician communication with AMOWCregarding hormone restoration.

I understand AMOWC’s practice is based upon his professional interpretation of the research and may not conform to guidelines issued by various professional medical organizations.

I understand nutritional supplementation and/or hormone restoration (HR) for improved health, quality of life, and disease prevention are not broadly accepted with regard to standardized medical practice, and no guarantee is made with respect to the outcome of such treatment.

I understand the actual incidence of various medical disorders including though not limited to cancers of the sex organs (breast, ovary, uterus or prostate), heart disease and stroke in persons on long-term HR may not be fully understood until more long-term trials/studies are performed.

I understand the risks and possible complications of HR as well as noncompliance with recommended dosage and agree to administer hormones as directed.

I understand blood/laboratory tests must be performed to monitor hormone levels and agree to have such tests as requested for continuation of HR treatment.