Patient Intake form | Shorewoord Elite Integrated Healthcare

Contact Information

Email *

Phone *

Address *

City *

State *

Zip code *

Emergency Contact Details

Emergency Contact Name *

Emergency Contact Number *

Relationship to Patient *

Service Request

Please let us know which program(s) you are interested in:- *

Primary Care Provider Information

Primary Care Provider *

Primary Care Provider Phone *

Health History Questionnaire

Check all that apply on your personal health history.

General Health *

Cancer *

Cardiovascular *

Respiratory *

Gastrointestinal *

Infection *

Psychiatric *

Do you or any family members have a history of thyroid cancer?

Yes

Date of your last annual exam / physical

Drugs Prescribed or Recommended

Please enter the drugs prescribed to you *

Drug 1
Drug 2
Drug 3

Please enter any over-the-counter drugs, vitamins, inhalers, etc. You can enter drug name, dosage, frequency and prescribed for. If not prescribed any, enter 'None'.

Allergies and Surgeries

Allergies *

Yes

Allergies, if yes, please list known allergies and reactions

Surgeries *

Yes

Surgeries, if yes, please list year, type of surgery, and reason for surgery:

Health Habits & Personal Safety

Exercise *

Yes

Exercise, If yes, please list type of exercise, frequency, and degree of intensity (mild, moderate, vigorous)

Have you used any hormones (prescribed or otherwise) or any other anabolic steroids in the past? (Our knowledge of this is critical in order to properly diagnose and prescribe). *

Yes

Hormones or Anabolic Steroids, If yes, please list type, when taken, and duration of use:

Please rate your Quality of Sleep *

(1- Worst, 10- Best)

Vitals

Height *

Weight *

Last menstrual cycle start date

Painful Intercourse

Yes

Have got checked your Hormone levels previously? *

Yes

If Hormone levels checked previously, how long ago and what was level?

Have you taken Hormone replacements previously? *

Yes

Select the date, if you have taken Hormone replacements

How did you hear about us? *

Walk In/Friend

Google

Facebook

Other

If other, please be sure to list their name so we can thank them.

Patient Signature: *

Clear

Draw your signature in the box

Patient Signature Date: *

Terms & Conditions *

I agree to terms & conditions and by providing my phone number, I agree to receive text messages from the Shorewood Elite Integrated Healthcare.