Dr. Lori’s Wellness Intake Form

1
Date
Date
Month
Day
Year
2

Wellness Intake

(Male clients disregard female related questions)

Please fill out form and CLICK SUBMIT

at the end before getting labs drawn.

Allow 48-72 hours for processing to receive lab script and/or set up symptom review appointment time.

**(BHRT) = Bioidentical Hormone Replacement Therapy)
3
Name / Date of Birth* This field is required.
First Name and Last Name
Date of Birth
4
Phone Number* This field is required.
Area Code
Phone Number
5
Pharmacy Number* This field is required.For General Prescriptions
Area Code
Phone Number
6
Email* This field is required.
example@example.com
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Marital Status * This field is required.
Married
Single
Widowed
9
Please state your Height / Weight / Occupation
10
Insurance
Insurance provider
Insurance type (ex- HMO, PPO)
Deductible Amount
Deductible Met ?
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Upload a copy of insurance cardPhoto Front & Back
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Select files to upload
Max. file size: 10.6MB
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12
Upload RECENT or RELEVANT LABS from the last 12 months
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Max. file size: 10.6MB
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13
Allergies: Please check all that apply
Pennicillin
Morphine
Dye Allergies
Codeine
Aspirin
Nitrate Allergy
Sulfa drugs
Food allergies
Pet allergies
Seasonal (pollen) allergies
Other
14
Please describe any allergic reaction you experienced from items mentioned on previous page.
15
Doctor's Name / Address / Phone
16
How did you arrive at the decision to consider Dr. Lori's Integrative Medicine Program or Bio-Identical Hormone Replacement (BHRT)
Doctor
Self
Family Friend
Other
Not Applicable
17
Please list Current Prescription Medications/Current Nutritional Supplements (Please bring any nutritional supplements you take to your consultation) Name Strength Date Started How often per day
18
Over-the-counter (OTC) issues: Please check all products that you use once or more per month.
Pain reliever
Sleep Aids
Antidiarrheal
Laxative/stool softener
Diet aids / weight loss products
Antacids
Others
19
Do you use any of the following:
Do you use Tobacco / Yes
No
Do you use Alcohol / Yes
No
Do you use Caffeine / Yes
No
20
How often and how much regarding Over the Counter drugsPlease name any other OTC being taken at this time
21
Hormones previously or currently taking (if any) Date Started Date Stopped Reason
22
Have you ever used oral contraceptives? - If yes, any problems using oral contraceptives? Please describe below:
23
Please check all that applyPlease check YES/NO box if you have had an ATYPICAL MAMMOGRAM OR PAP SMEAR
Mammogram / Yes
No
Pap Smear / Yes
No
24
Date of last Mammogram and or Pap Smear PLEASE TYPE DATES OF LAST TESTS AND DETAILS OF ANY ABNORMAL TESTS
25
When was your last cycle or first day of last cycle & how many days did it last?
26
Do you have, or have you ever had Premenstrual Syndrom (PMS)
No
Yes
27
Do you have, or have you ever had Premenstrual Syndrome (PMS)? If yes please explain symptoms:
28
Since you first began having menses, have you ever had what YOU would consider to be abnormal cycles?
No
Yes
29
If yes to the last question, please explain your symptoms and at what ages(s) this occurred:
30
How many pregnancies have you had? / How many children?
31
Please click below
Any interrupted pregnancies / No
Yes
Have you had a hysterectomy? / No
Yes
Ovaries removed? / No
Yes
Have you had a tubal ligation? / No
Yes
32
Please check all that apply to you. * This field is required.
NONE
Allergies
Arthritis
Asthma
Cancer
Clotting Problems
Depression
Diabetes
Eczema
Fibrocystic breast
Ulcers
Anxiety Disorder
Stroke
Heart Disease
High Cholesterol or Lipids
High Blood Pressure
Eye Disease
Migraines/headaches
Osteoporosis
Thyroid Disease
Ulcer
Emphysema / COPD
Fibromyalgia
GERD
Seizure Disorder
Irritable Bowel
Other
33
Did any of your Immediate Family have any of the disorders on previous page- please describe
34
Please select the following* This field is required.Please indicate your symptoms (0-5) for the following conditions by using the following numeric scale: 0 being no symptoms at all up to 5 being the worst symptoms imaginable (Please type the number in field below)
0 Select
1 Select
2 Select
3 Select
4 Select
5 Select
Fibrocystic Breast
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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Row 0, Column 5
Weight Gain
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Heavy Irregular Menses
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Hot Flashes
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Dry Skin / Hair
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Anxiety
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Depression
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Night Sweats
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Vaginal Dryness
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Headaches
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Irritability
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Mood Swings
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Breast Tenderness
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Sleep Disturbances / Insomnia
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Fluid Retention
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Breakthrough Bleeding
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Fatigue
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Memory Loss
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Incontinence/frequent urination
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Arthritis
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Difficulty reaching orgasm
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Decreased libido
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Hair Loss
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Indigestion
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Cold hands/feet
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Diarrhea and /or constipation
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Erectile Dysfunction
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Failed morning erections
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Urinary Retention
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Urinary Frequency (night-time especially)
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Food Sensitivity / Allergy
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Sensitivity to Heat/Cold
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Difficulty Waking Up
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Joint Pains
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Visual Changes / Blurred Vision
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Loss of Smell
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Loss of Taste
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Chronic Post Nasal Drip
Row 37, Column 0
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Chronic Nasal Congestion
Row 38, Column 0
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Shortness of Breath
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Cough
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Lack of Exercise Tolerance
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Muscle Cramping/Spasm
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Reynaud's Syndrome (white fingertips suddenly)
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History of Lyme Disease
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History of Chronic HPV
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History of Chronic Mold Exposure
Row 46, Column 0
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Fibrocystic Breast
Weight Gain
Heavy Irregular Menses
Hot Flashes
Dry Skin / Hair
Anxiety
Depression
Night Sweats
Vaginal Dryness
Headaches
Irritability
Mood Swings
Breast Tenderness
Sleep Disturbances / Insomnia
Fluid Retention
Breakthrough Bleeding
Fatigue
Memory Loss
Incontinence/frequent urination
Arthritis
Difficulty reaching orgasm
Decreased libido
Hair Loss
Indigestion
Cold hands/feet
Diarrhea and /or constipation
Erectile Dysfunction
Failed morning erections
Urinary Retention
Urinary Frequency (night-time especially)
Food Sensitivity / Allergy
Sensitivity to Heat/Cold
Difficulty Waking Up
Joint Pains
Visual Changes / Blurred Vision
Loss of Smell
Loss of Taste
Chronic Post Nasal Drip
Chronic Nasal Congestion
Shortness of Breath
Cough
Lack of Exercise Tolerance
Muscle Cramping/Spasm
Reynaud's Syndrome (white fingertips suddenly)
History of Lyme Disease
History of Chronic HPV
History of Chronic Mold Exposure
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35
What are your goals with taking BHRT or with Dr. Lori's Integrative Medicine & Wellness Testing?* This field is required.
36
Please list or explain any symptoms that you are experiencing not listed above or expand upon your symptoms here* This field is required.
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37
Please state any specific questions you have about BHRT or Integrative Medicine Programs and Testing.
38
By typing your name and date below, we will accept this as your signature and acknowledge that you have read and reviewed this questionnaire.NAME DATE
39
PLEASE NOTE BY TYPING YOUR NAME AND DATE BELOW, YOU ACKNOWLEDGE THAT REFRESH IS NOT FINANCIALLY RESPONSIBLE FOR ANY LABS THAT ARE NOT COVERED BY YOUR INSURANCE COMPANY. WE DO OUR BEST TO GIVE YOU THE MOST ECONOMICAL OPTION POSSIBLE AND HAVE NEGOTIATED PRICES FOR SELF PAY OPTIONS WITH SOME LABS IF REQUIRED. IT IS YOUR RESPONSIBILITY TO CALL YOUR INSURANCE REGARDING LABORATORY CHARGES IN AND OUT OF NETWORK OPTIONS & DEDUCTIBLE INFORMATION.* This field is required.NAME DATE
40
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