Female BioTe Intake Form Female BioTe Paperwork "*" indicates required fields Step 1 of 4 25% PhoneThis field is for validation purposes and should be left unchanged.Name* First Last Weight (lbs)*Birthday* MM slash DD slash YYYY Occupation*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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*May we send messages via text regarding appointments to your cell? Yes No Emergency ContactName* First Last Phone*Relationship to Patient*Primary Care Physician's Name*Primary Care Physician's Phone Number and Address:*Marital Status Married Divorced Widow Living with Partner Single In the event we cannot contact you by the means you have provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below, you are giving us permission to speak with your spouse or significant other about your treatment. Please indicate their name, number and relationship to you below.*How did you hear about us?*GrouponFriendFamilyFacebookReal SelfTwitterGoogleInstagramYelpOtherIf selected "Friend" or "Family", please specify who referred you: Social HistoryCheck Any Areas That Apply:* I am sexually active I have completed my family My sex life has suffered I want to be sexually active. I have NOT completed my family. I have not been able to have an orgasm or it is very difficult. I do not want to be sexually active HabitsI smoke cigarettes or cigars* Yes No If yes, how many do you smoke per day?I use e-cigarettes* Yes No If yes, how often do you use it per day?I use caffeine* Yes No If yes, how often do you use it per day?I drink alcoholic beverages* Yes No If yes, how often do you drink per week?Female Medical HistoryAllergies to medications, latex or any other known allergies:*(type NONE if you have no allergies)Have you ever had any issues with local anesthesia?* Yes No If yes, please explain:Please list any current medications (Oral and/or Topical) and/or vitamins:*(type NONE if you take no medications or vitamins)Please list current and past hormone replacement therapy*(type NONE if you have never done hormone replacement therapy)Surgeries. Please list all and when:*(type NONE if you have had no surgeries)Please list ANY other health related conditions, concerns or pertinent information not previously identified:*(type NONE if you have no conditions or concerns)Last menstrual period (estimate year if unknown):* Preventative Medical Care* Medical/GYN exam in the last year Bone density in the last 12 months Mammogram in the last 12 months Pelvic ultrasound in the last 12 months None Pertinent Medical/Surgical History* Breast cancer Uterine cancer Ovarian cancer Polycystic ovaries/PCOS Acne Excess facial/body hair Infertility Endometriosis Epilepsy or seizures Fibrocystic breast or breast pain Uterine fibroids Irregular or heavy periods Menstrual migraines Hysterectomy with removal of ovaries Partial hysterectomy (uterus only) Ophorectomy removal of ovaries only None Birth Control Method* Menopause Hysterectomy Tubal ligation Birth control pills Vasectomy IUD Infertility Other Pertinent Medical/Surgical History* Chronic liver disease (hepatitis, fatty liver, cirrhosis) Diabetes Thyroid disease Arthritis Depression/anxiety Psychiatric disorder Cancer Any form of hepatitis or HIV Lupus or other autoimmune disease Frequent blood donation or history of anemia Fibromyalgia Chronic kidney disease Dialysis High blood pressure Heart bypass High cholesterol Hair thinning Heart disease Stroke and/or heart attack Blood clot, DVT and/or a pulmonary embolism Heart arrhythmia or atrial fibrillation none Hot Flashes* Never Mild Moderate Severe Very Severe Sweating (night sweats or increased episodes of sweating)* Never Mild Moderate Severe Very Severe Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)* Never Mild Moderate Severe Very Severe Depressive mood (feeling down, sad, on the verge of tears, lack of drive)* Never Mild Moderate Severe Very Severe Irritability (mood swings, feeling aggressive, angers easily)* Never Mild Moderate Severe Very Severe Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)* Never Mild Moderate Severe Very Severe Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)* Never Mild Moderate Severe Very Severe Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)* Never Mild Moderate Severe Very Severe Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)* Never Mild Moderate Severe Very Severe Bladder problems (difficulty in urinating, increased need to urinate, incontinence)* Never Mild Moderate Severe Very Severe Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)* Never Mild Moderate Severe Very Severe Difficulties with memory* Never Mild Moderate Severe Very Severe Problems with thinking, concentrating or reasoning* Never Mild Moderate Severe Very Severe Trouble thinking of the right word to describe persons, places or things when speaking* Never Mild Moderate Severe Very Severe Trouble thinking of the right word to describe persons, places or things when speaking* Never Mild Moderate Severe Very Severe Difficulty learning new things* Never Mild Moderate Severe Very Severe Increase in frequency or intensity of headaches or migraines* Never Mild Moderate Severe Very Severe Hair loss, thinning or change in texture of hair* Never Mild Moderate Severe Very Severe Weight gain or difficulty losing weight despite diet and exercise* Never Mild Moderate Severe Very Severe Dry or wrinkled skin* Never Mild Moderate Severe Very Severe Feel cold all the time or have cold hands or feet* Never Mild Moderate Severe Very Severe Pellet Protocol InformationANTIDEPRESSANT WEAN PROTOCOL If you are taking an SSRI or SNRI antidepressant such as Prozac, Zoloft, Lexapro, Pristiq, Effexor, Viibryd, the generic equivalents or others and have NOT had long-term issues with generalized anxiety disorder, bipolar or major depressive disorders, you may be able to slowly wean off of your antidepressants. We recommend you wean off of these slowly as soon as you start to feel better with your pellets. This is usually after about 4 weeks and only if you are feeling better and ready to start the weaning process. These antidepressants have many side effects. You can feel tired, sleepy, have weight gain or difficulty achieving an orgasm (to name few) which is everything we are trying to improve. It is very difficult for the pellet therapy to have adequate results in some patients who are still on these medications. You are NOT deficient in these antidepressant medications. You are deficient in hormones. As we restore your hormone levels to normal with pellets, your symptoms of anxiety and/or depression should be relieved naturally. You should be able to wean off your antidepressant. Go slowly -- especially if you have been taking them for a while. While taking an SSRI or SNRI, your brain relies on these medications to get serotonin (the calming, feel good hormone) and doesn’t make its own. If you stop your medication abruptly, you can go through withdrawals. Symptoms of abrupt cessation may include headache, GI distress, faintness, body aches, chills, and strange sensations of vision or touch. Some patients withdrawing from Effexor may describe the feelings of “electric shocks”. You may also experience depression or anxiety symptoms returning. When you wean slowly, your brain has time to catch up, wake up, and start making its own serotonin again. If you are on a high-dose or capsule, you may have to request a lower dose to use in the transition. WE RECOMMEND THE FOLLOWING PROTOCOL TO HELP: 1. Take your pill every other day for 2 weeks. 2. Then every 3 days for 2 weeks. 3. Then every 4 days for 2 weeks and so on until you are down to one a week, then STOP. If at any point you feel badly or “off”, go back to the lowest dose you felt good on and take the wean a bit slower. If you are on a high dose of the medication, you may need an additional prescription for a lower strength so you can slowly transition from the higher to the lower strength and then wean as described above.
