Name
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First Name
Last Name
Insurance Provider
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*PLEASE NOTE: We only take commercial plans and can NOT work with any Medicare or Medicaid/Mass Health plans, even if combined with a plan listed below.
Do you have a:
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Insurance ID number:
Date of Birth
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MM
DD
YYYY
Email
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Phone
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(###)
###
####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Why would you like to be seen?
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What are two main questions or symptoms you would like to address?
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Who have you raised these concerns with, and what was discussed?
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When did you have your first period?
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Did you have a period every month?
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Are you still having periods? If no when was your last?
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Are you still having periods? If no when was your last?
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How often do you exercise?
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Do you follow any specific diet or nutrition plan? (Yes/No, please describe)
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How would you describe your stress levels?
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Low
Moderate
High
What is your biggest source of stress?
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How often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
Do you use any kind of tobacco products?
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Yes
No
What self-care practices do you engage in to support your well being? (e.g., yoga, or other exercise, meditation, therapy)
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Medical Conditions:
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Are you currently taking any medication?
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Medications:
Supplements/vitamins:
Surgical History (please list any surgeries you have had with dates)
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Family History-ONLY immediate family, unless there is pertinent information i.e., 2 aunts, grandmother with breast cancer. Most notably: cancer, diabetes, obesity or overweight, cardiovascular disease (heart attacks, strokes, high cholesterol, high blood pressure), blood clots or clotting disorder, osteoporosis/hip fractures or vertebral (spine) fractures.
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