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, or weight loss candidate at this time. Please complete the checklist before your appointment. 1. Either complete the online form below and you will be emailed the consent forms, lab requisition, and pelvic ultrasound prescription, or print and complete the Women’s New Patient Packet (click here to download) and email, fax, or mail the completed questionnaire and signed consent forms to our office. The New Patient Packet contains all the necessary forms, lab requisition, and pelvic ultrasound prescription. 2. Have your blood lab drawn. After completing the new patient form below you will be emailed a lab requisition.. 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. After completing the new patient form below you will be emailed a prescription for this ultrasound. 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: Initial Consultations – Physician (60 minutes) : $250 Follow up Consultations – Physician (60 minutes) : $250 Annual Treatment Plan Review $100 Female pellet insertion (every 4 to 6 months): Approximately $550 Weight Loss Fee Schedule: Consultations – Nurse Practitioners (45 minutes): $200 Follow-up Consultations – Nurse Practitioner: $150 If you are interested in both hormone replacement and weight loss they both will be covered in the same consultation. Purpose of Visit* Hormone Replacement with Pellets Weight Loss Program Both Patient Name* First Middle Last What do you prefer to be called (nickname)? Home Phone*Cell Phone*Patient's SSN# or Driver's License No.* Email* Home Address (no PO Box)* 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 Age:* Date of Birth:* MM slash DD slash YYYY Referred by: Primary Medical Doctor: Current OB/GYN or Urologist: Current or Previous Occupation: Employer: Which office will you be visiting?* St. Louis Kansas City No Preference Preferred Pharmacy Name:* Preferred Pharmacy Phone:*Preferred Pharmacy Address:* Emergency Contact Name: Relationship to Emergency Contact: Emergency Contact Phone:Are you currently taking any medications?* Yes No Current Medications (List all current medications)Medication NameDoseFrequencyReason for Taking Are you currently taking any Supplements?* Yes No Current Supplements (List all current supplements)Supplement Name and BrandDoseFrequencyReason for Taking Do you have any allergies (Food, Drug, Other)?* Yes No Allergies and Reactions (List all Food, Drug, other)AllergyReaction Current Symptoms (check all that apply)* 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 Headaches Decreased Muscle Mass & Strength Joint Aches/Arthritis Dry Eyes Poor Balance & Coordination Weight Gain Belly Fat Ringing in Ears Difficulty Taking Oral Birth Control Pills Hot Flashes Night Sweats Dry Vagina Painful Intercourse Heavy or Irregular Periods Height has Decreased Bladder Spasms Bladder Infections PMS Felt Better Pregnant Dry Skin Constipation Thinning Eyebrows Thinning Eyelashes Thinning Hair Cold All of the Time Swelling All Over Body Brittle Nails Ache All Over Poor Immunity Snoring Other List any other symptoms:Martial Status* Married Divorced Separated Single Widowed Birth Control Method (you must have one of the following for hormone replacement):* Menopause (no period > 12 months) Hysterectomy (uterus removed) Oophorectomy (ovaries removed) Tubal Ligation (tubes tied) Essure I only have sex with women Vasectomy Mirena or Progesterone IUD Paragard or Copper IUD Other: List Other Birth Control Method Past Medical History (Check all that apply)* ADD or ADHD Addison’s Disease Adrenal Fatigue Alcoholism, AA, Drug Dependence Anxiety Arthritis Autoimmune Disease (Rheumatoid, Lupus, etc.) Blood Clot/Pulmonary Embolism Breast Cancer Cold Sores Colon Cancer Concussion Contact Sports Cushing’s Disease Depression Pre-Diabetes Diabetes Type I Diabetes Type II Emphysema/COPD Fatty Liver Disease Fibromyalgia Glaucoma Heart Arrhythmia Heart Attack Heart Murmur Hemochromatosis Hepatitis Herpes High Blood Pressure High Cholesterol HIV or AIDS Hyperthyroid (overactive thyroid) Hypothyroid (under-active thyroid) Insulin Resistance or metabolic syndrome IVF or other fertility treatments Kidney disease Manic Depression or Bipolar Disorder Multiple Sclerosis (MS) Narcolepsy Osteopenia Osteoporosis Ovarian Cancer Overweight or Obese Parkinson’s Disease Polycystic Ovarian Syndrome (PCOS) Restless Leg Syndrome (RLS) Schizophrenia Seizures or Epilepsy Sleep Apnea Stroke Tuberculosis (TB) Uterine cancer I use oxygen I use a C-Pap machine Other List other Medical History Number of pregnancies:*Number of miscarriages/abortions:*Number of deliveries:*Number of children:*Last Menstrual Period:* Past Surgeries Gastric Bypass, Gastric Sleeve, Lap Band, or other weight loss surgery Joint Replacement Pacemaker Open Heart Surgery or Stents Gallbladder removed Pain stimulator or any other implanted electrical device Uterus Removed Ovaries Removed Breast Implants Uterine Ablation D&C Other: List all other surgeriesI smoke Cigarettes/Cigars* Yes No How many packs/day for how many years? I used to smoke Cigarettes/Cigars* Yes No How many packs/day, how many years, and year you quit? I Drink More Than 10 Drinks of Alcohol/Week* Yes No I am a Recovering Alcoholic* Yes No I Use or Have Used Marijuana in the past year* Yes No I Use or Have Used Cocaine in the past year* Yes No I Use or Have Used Heroin in the past year* Yes No Social History (Check all that apply)* I have completed my family I still want to have children I am sexually active I want to be sexually active I do not want to be sexually active My sex life is good My sex life has gotten worse I am heterosexual I am homosexual I am bisexual I have a new partner in the last 3 years I have never had an orgasm Other: Other Social History: Previous hormone replacement (Check all that apply) None Pellets Shots Troches Patch Pill Vaginal Ring Creams/gels applied on the skin or in the vagina Previous Growth Hormone Replacement Other Other hormone replacement: Family History of Autoimmune DiseaseNoneMotherFatherSiblingChildrenFamily History of Blood ClotsNoneMotherFatherSiblingChildrenFamily History of Cancer, BreastNoneMotherFatherSiblingChildrenFamily History of Cancer, ColonNoneMotherFatherSiblingChildrenFamily History of Cancer, OvarianNoneMotherFatherSiblingChildrenFamily History of Cancer, ProstateNoneMotherFatherSiblingChildrenFamily History of Cancer, TesticularNoneMotherFatherSiblingChildrenFamily History of Cancer, UterineNoneMotherFatherSiblingChildrenFamily History of Cancer, OtherNoneMotherFatherSiblingChildrenFamily History of DementiaNoneMotherFatherSiblingChildrenFamily History of Diabetes, Type INoneMotherFatherSiblingChildrenFamily History of Diabetes, Type 2NoneMotherFatherSiblingChildrenFamily History of Heart Attack or StentsNoneMotherFatherSiblingChildrenFamily History of Other Heart ConditionsNoneMotherFatherSiblingChildrenFamily History of HemochromatosisNoneMotherFatherSiblingChildrenFamily History of ObesityNoneMotherFatherSiblingChildrenFamily History of PrediabetesNoneMotherFatherSiblingChildrenFamily History of StrokeNoneMotherFatherSiblingChildrenFamily History of SuicideNoneMotherFatherSiblingChildrenFamily History of Thyroid Disease – high or lowNoneMotherFatherSiblingChildrenList other family history Preventive 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 Other: List other preventative medical care: Current Diet (Check all that apply)* I eat anything I want I don’t eat much and gain weight anyway Gluten free Low carb Low fat Keto Intermittent Fasting Vegan Vegetarian Pescatarian Blood type specific diet Atkins/South Beach Weight Watchers Other Other Diet: Number of meals/snacks per day? Current Exercise (Check all that apply) None Cardio Weightlifting I have a very physical job I am a long distance runner, biker, or triathlete Other: Minutes of cardio per day/week? Minutes of weightlifting per day/week? Other current exercise: Height (ft - in) Weight (lbs) Goal Weight (lbs) Current dress size Goal dress size Do you have to take antibiotics for routine dental cleanings?* Yes No Other problems or concerns not listed in this questionnaire:Electronic Signature:* I attest that all the information I give is true.