Become a Female Hormone or Weight Loss Patient Thank you for your interest in BioBalance® Health. In order to determine if you are a candidate for bioidentical hormone pellets for menopause and perimenopause, there are several things we need to assess. We will evaluate your information prior to your consultation to determine if BioBalance® Health can help you “get your life back”. If you are under the age of 18, pregnant, or plan to become pregnant, you are not a hormone replacement candidate at this time. This restriction does not apply to weight loss patients Please complete the checklist before your appointment. 1. Fill out the online form below (you will be emailed the consent forms and lab requisitions), or print and complete the Women’s New Patient Packet (click here to download). Email, fax, or mail the completed questionnaire and signed consent forms to our office. 2. Have your blood lab drawn. Included are lab requisitions for Quest Laboratory, LabCorp, and there is a generic lab requisition if your insurance company does not cover Quest or LabCorp laboratories. You must fast for 12 hours and have your blood drawn before 9:00 AM. It is up to you to find out if your insurance company will cover the cost of the labs. If not, you may have your lab drawn at Quest at the BioBalance Health discount (you will need to pay BioBalance® Health directly. PLEASE NOTE: It takes 2 weeks for us to receive the results in our office. 3. Hormone Replacement Patients Only - If you have a uterus, you must have a pelvic ultrasound. Enclosed is a prescription for this ultrasound. Because of our relationship with Balanced Care for Women in St. Louis (we share our parking lot), they have tailored their ultrasound service specifically to provide the detailed report that Dr. Maupin and Dr. Sullivan prefer. Normal insurance deductibles apply regardless of the imaging center you select for your ultrasound. If you select Balanced Care for your ultrasound, please call their office Tuesday through Friday at (314) 993-7009 and advise the scheduling desk that you need an ultrasound for BioBalance Health. Balanced Care for Women will forward your ultrasound report to BioBalance Health. 4. Hormone Replacement Patients Only - You will need a mammogram (within the last 1 year if over age 40). Mail or fax copies to our office. Once we receive ALL of your information and lab results, we will contact you to schedule your initial consultation. Thank you and we look forward to seeing you soon! BioBalance Health 10800 Olive Blvd. Creve Coeur, MO 63141 Attn: Receptionist Phone: (314) 993-0963 Fax: (314) 218-3999 Email: email@example.com Female Hormone Replacement Fee Schedule: Consultations – Physician (45 minutes) : $250 Consultations – Nurse Practitioners/Nurse (45 minutes): $200 Follow up Consultations – Physician: $250 Follow-up Consultations – Nurse Practitioner/Nurse: $150 Annual Treatment Plan Review $100 Female pellet insertion (every 4 to 6 months): Approximately $550 Weight Loss Fee Schedule: Consultations – Physician (45 minutes) : $250 Consultations – Nurse Practitioners/Nurse (45 minutes): $200 Follow up Consultations – Physician: $250 Follow-up Consultations – Nurse Practitioner/Nurse: $150 If you are interested in both hormone replacement and weight loss they both will be covered in the same consultation. What is the purpose of your visit?*Hormone ReplacementWeight Loss ProgramBoth Hormone Replacement and Weight Loss ProgramName:* First Middle Last Home Phone*Cell Phone*Email* Home Address Information* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you married?*YesNoWhich office will you be visiting?*Kansas CitySt. LouisAge:*Date of Birth:* Date Format: MM slash DD slash YYYY Patient's SSN# or Driver's License No.*Emergency Contact:Emergency Contact's Relationship to you:Emergency Contact's Main Phone#:Emergency Contact's Alternate Phone#:Occupation:Employer:Work Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern 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GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work Phone:May we remind you of appointments by texting cell phone home phone work phone email Do you have any allergies (Food, Drug, Other)?*YesNoList all allergies and reactions*Referred by:Current OB/GYN or Urologist:Primary Medical Doctor:Are you currently taking any medications?*YesNoList all medications, dose, and frequency*Are you currently taking any supplements?*YesNoList all supplements, dose, and frequency*Last menstrual period:Number of pregnancies:Number of Children:History of present illness/symptoms* Low or No Sex Drive (Libido) Fatigue or Lack of Energy Infrequent or Absent Orgasms Depression Anxiety Change in Mood or Irritable Insomnia Memory Loss or Foggy Thinking Feeling Hopeless Low or No Motivation New Migraine Headaches Decreased Muscle Mass & Strength Joint Aches/Arthritis Dry Eyes Poor Balance & Coordination Weight Gain Belly Fat Ringing in Ears Hot Flashes or Night Sweats Dry Vagina Painful Intercourse Heavy or Irregular Periods Height has Decreased, Osteoporosis, or Osteopenia Bladder Spasms Bladder Infections PMS Felt Better Pregnant Dry Skin Constipation Thinning Eyebrows/Eyelashes Thinning Hair Cold All of The Time Swelling All Over Body Brittle Nails Ache All Over Poor Immunity Difficulty Taking Oral Birth Control Pills Snoring Other Symptoms Other Symptoms:*Birth Control Method: (You must be in menopause, have had a hysterectomy or use birth control to use pellet therapy.)* Menopause Hysterectomy Tubal ligation Birth control pills Abstinence Vasectomy Mirena IUD Other IUD Other: List Other Birth Control Method*Surgical History D&C Gastric Bypass, Lap Band, or Other Surgery for Weight Loss Hysterectomy (Uterus Removed) Joint Replacement Open Heart Surgery or Stents Ovaries Removed Pacemaker Uterine Ablation LIST OTHER SURGERIES OR PROCEDURES List all other surgeriesPast Medical History:* ADD or ADHD Addison’s Disease Adrenal Fatigue Alcoholism, AA, Drug Dependence Arthritis Autoimmune Disease (Rheumatoid, Lupus, etc.) Blood Clot/Pulmonary Embolism Breast Cancer Colon Cancer Concussion Contact Sports Cushing’s Disease Depression/Anxiety Diabetes Type I Diabetes Type II Emphysema/COPD Fatty Liver Disease Fibromyalgia Glaucoma Heart Arrhythmia Heart Attack Heart Murmur Hemochromatosis Hepatitis High Blood Pressure High Cholesterol HIV or AIDS Hyperthyroid Hypothyroid Insulin Resistance In Vitro Fertilization (IVF) or other fertility treatment Kidney disease Manic Depression or Bipolar Disorder Multiple Sclerosis (MS) Narcolepsy Osteopenia or Osteoporosis Ovarian Cancer Overweight or Obese Polycystic Ovarian Syndrome (PCOS) Restless Leg Syndrome (RLS) Schizophrenia Seizures or Epilepsy Sleep Apnea Stroke Tuberculosis (TB) Uterine cancer OTHER MEDICAL PROBLEMS OR CANCERS: List other past medical history*Social History: I am in menopause I am still fertile I have completed my family I have permanent birth control I am married or in a committed relationship I am sexually active I want to be sexually active I am heterosexual I am homosexual I am bisexual I have a new partner in the last 3 years My sex life is good My sex life has gotten worse I had orgasms before I was 40, but not now I have never had an orgasm I have experience using a vibrator Do you use Oxygen?*NoYesDo you use a C-Pap Machine?*NoYesI smoke cigarettes or cigars*NoYesIf you smoke how many packs/day/# of years?I used to smoke cigarettes or cigars*NoYesIf you previously smoked, how many packs/day/# of years?I drink more than 10 drinks of alcohol/week*NoYesI use or have used marijuana in the past year*NoYesI use or have used cocaine*NoYesExercise History:* I don’t exercise Normal daily activity is what I consider exercise I have a very physical job I exercise daily for 45 min or more I exercise 3-5x/week for 45 min or more I lift weights I am a long-distance runner, biker, or triathlete OTHER EXERCISE What other types of exercise do you do?*Current Weight (lbs)Goal Weight (lbs)Current Height (ft - in)Current dress sizeGoal dress sizeDiet History* I eat anything I want I don’t eat much and gain weight anyway I have gained weight in my abdomen I do not eat wheat (gluten sensitivity/intolerance) I eat a low carb diet I eat a low-fat diet I eat 3 meals a day I eat 6 small meals a day Vegan/Vegetarian Intermittent Fasting Keto Diet Atkins/South Beach Diet Weight Watchers Other Diet Information/Previous Diets Tried: List other diet information/previous diets tried?*Family History (Mother/Father/Sister/Brother): Autoimmune Disease Blood Clots Breast Cancer Colon Cancer Dementia Diabetes, Type I Diabetes, Type 2 Heart Attack or Heart Disease Hemochromatosis Obesity Prediabetes Stroke Thyroid Disease – high or low Uterine Cancer OTHER FAMILY MEDICAL PROBLEMS OR CANCERS: List all other family medical problems/cancersPreventive Medicine History: PCP Visit in the last year OBGYN Visit in the last year Urologist Visit in the last year Mammogram in the last year DEXA or Bone Density Scan in the last year Pelvic Ultrasound in the last year Colonoscopy in the last 10 years Hormone replacement I have used in the past:* None Pellets Cream/Gel Shots Troches Patch Oral pills synthetic (Ogen, Premarin, Estrace, etc.) Vaginal ring Sublingual or buccal tablets (dissolve in the mouth) Other What other type of hormone replacement have you used in the past?*Nothing has worked well so far so: I am here for bioidentical hormone pellet therapy Other problems or concerns not listed in this questionnaire:Electronic Signature:* I attest that all the information I give is true.