Become a Female Hormone Replacement 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 candidate at this time. Please complete the check list 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 do not have sex for 48 hours prior to the blood draw. 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. 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 prefers. 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 Dr. Maupin. Balanced Care for Women will forward your ultrasound report to Dr. Maupin. 4. You will need a current Pap smear (within the last 3 years) and mammogram (within the last 1 year and 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.comName:* First Middle Last Home Phone*Cell Phone*Email* Enter 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:* 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 SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Work Phone:May we remind you of appointments by texting cell phone home phone work phone email Allergies:Drug Allergies:Referred by:Current OB/GYN or Urologist:Primary Medical Doctor:Current Meds:Current supplements/vitamins:Last menstrual period:Number of pregnancies:Number of Children:Current Symptoms: Decreased or absent sex drive (libido) Fatigue and lack of energy Infrequent or absent orgasms Change in mood, anxiety and/or depression Insomnia Declining mental ability and memory Feeling of hopelessness and no motivation New migraine headaches Diminished strength and exercise tolerance Muscle shrinkage Joint aches and/or new onset of arthritic symptoms Dry eyes Poor balance and coordination Weight gain New or increased cellulite Ringing in the ears Hot flashes and night sweats Dry vagina or painful intercourse Dry and wrinkled skin Height has decreased, osteoporosis or osteopenia Bladder spasms Bladder infections PMS Felt better when I was pregnant Cold all the time Swelling all over the body Constipation Hair falling out or breaking off Brittle nails Stay up for over 24 hours Difficulty taking oral birth control pills 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: Surgeries: Lap-band surgery or other surgery for obesity Hysterectomy Removal of ovaries Joint replacement Heart surgery Pacemaker Other Date of your Lap-band or obesity surgery:* Date of your Hysterectomy:* Date your ovaries were removed:* Date of you Joint replacement surgery:* Date of your heart surgery:* Date of your pacemaker surgery:* Other Surgeries & Date of Surgery*If you have had additional surgeries, please provide the type and the date you had it on here:Medical History: Any type of hepatitis or HIV Breast cancer Uterine cancer Colon cancer Ovarian cancer Other cancer Blood clot or clotting disorder Heart attack Stroke Vascular disease High blood pressure High cholesterol Heart arrhythmia Emphysema (COPD) TB (Tuberculosis) Glaucoma ADD, ADHD Depression/Anxiety Manic depression (bipolar) or mania Schizophrenia Psychological/psychiatric illness Restless leg Sleep apnea Narcolepsy Arthritis Rheumatoid arthritis Osteopenia or osteoporosis Fibro myalgia Lupus or autoimmune disease Chronic disease Chronic fatigue Adrenal fatigue Multiple sclerosis Diabetes type I Diabetes type II Hypoglycemia Insulin Resistance Hypothyroid disease Hyperthyroid disease Addisons disease or Cushings disease Kidney disease Liver disease What type of hepatitis or HIV:*Other Types of Cancer:*Type of psychological/psychiatric illness:*Social History: I am menopausal I have completed my family I have permanent birth control I am married I have a partner I am in a committed relationship I am Heterosexual I am Homosexual I am Bisexual Habits: I smoke cigarettes I drink more than 12 drinks of alcohol per week I am a recovering alcoholic I drink everyday I use or have used marijuana in the last year I use cocaine or heroin or have a history of using them If you do smoke, how many packs per day?*Sexual History (present): I have a new partner in the last 3 years My sex life is good I have the ability to have an orgasm I have never had an orgasm I had orgasms before I was 40, but not now I had sexual fantasies in the past I still have sexual fantasies My sex life has gotten worse after 40 My sex life is better than before 40 I have experience using a vibrator Exercise History: I don’t exercise I have a very physical job so I don’t exercise in addition I exercise every day I exercise more than three times a week for over 50 minutes Normal daily activity is what I consider exercise I am a long distance runner I lift weights Other How many minutes a day do you exercise?Current Weight (lbs)Ideal Weight (lbs)Current Height (ft - in)How many times a week do you lift weights?What other types of exercise do you do?Diet: I eat anything I want I don’t eat much but gain weight anyway I have gained weight in my belly since I turned 40 I eat a balanced diet, 3 times a day I eat 6 small meals a day I don’t eat meat (gluten intolerance) I limit carbohydrates I eat a low fat diet Atkins/South Beach Diet Vegan/Vegetarian Special diet or restrictions Other What other type of diet do you do?Preventive Medical Care: Medical/GYN exam in the last year Mammogram in last 12 months Bone density in last 12 months (if over 50) Pelvic ultrasound in last 12 months (If you have a uterus) Family History (Mother/Father/Sister/Brother): Heart Disease Breast Cancer Uterine cancer Stroke Arrhythmia Diabetes Alzheimer’s / Dementia any type Blood clots Rheumatoid arthritis/Lupus Thyroid disease — high or low Osteoporosis Hemochromatosis Hormone replacement I have used in the past: Oral pills synthetic (Ogen, Premarin, Estrace, etc.) Patch Vaginal ring Other What other type of hormone replacement have you used in the past?*Bioidentical Hormone replacement I have used in the past: Pellets Creams/gels applied on the skin or in the vagina Sublingual or buccal tablets (dissolve in the mouth) 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.