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Choose The Location Nearest You
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Fredericksburg, VA
Greenville, SC
Richmond, VA
Which services are you interested in
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BHRT
Weight Loss
Sexual Wellness
Aesthetics
Name
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First
Last
Date of Birth
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Sex:
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Age:
Address
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Street Address
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Email
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Enter Email
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How were you referred to us?
Family Physician and/or Primary Health Care Provider:
Do you request your protected health information to be released to you:
Yes
No
Do you request your protected health information be released to anyone other than you?
Yes
No
Name:
Phone
Relationship to patient:
Reason for Release:
Do you request your protected health information be disclosed to your Family Physician/Primary Care Provider?:
Yes
No
Primary Care Physician:
Physician/Primary Care Phone
Fax:
Additional Medical Record Release Recipients:
Phone
Fax: .
Occupation:
Position:
Employer:
Work Phone
Marital Status:
Single
Married
Divorced
Widowed
Spouse/Significant Other’s Name:
Phone
Emergency Contact:
Emergency Contact Phone
How did you hear about Renew Health and Wellness?
FAMILY HISTORY
(All forms)
Father's Age
Father's Health
Age at Death
Cause
Mother's Age
Mother's Health
Age at Death
Cause
Sibling's Age
Sibling's Health
Age at Death
Cause
Sibling 2 Health
Siblings Age
Age at Death
Cause
Weight Loss Questions
How did your weight gain start? (Describe)
Your present weight:
Your weight goal:
What is your highest weight? (excluding pregnancy):
Your age:
What is your lowest weight as an adult?
Your age:
# of years ago:
Have you ever stayed the same weight for 10 or more years?
Yes
No
Have you attempted to lose weight before?
Yes
No
Pounds lost?
How long did it take?
Previous weight loss methods? (please list)
Add
Remove
Where and when do you overeat?
Medical History: Please check all that apply
Please specify your genetic origin:
African American
Asian
Caucasian
Hispanic
Mediterranean
Middle Eastern
Native American
Other
Do you now or have you ever had: (check all that apply)
Diabetes
Heart murmur
Crohn’s disease
High blood pressure
Pneumonia
Colitis
High cholesterol
Chronic Diarrhea
Pulmonary embolism
Emphysema/Bronchitis
Anemia
Back Ache
Hypothyroidism
Asthma
Jaundice
Goiter
Emphysema
Hepatitis
Cancer (type)
Stroke
Stomach or peptic ulcer
Leukemia
Epilepsy (seizures)
Rheumatic fever
Psoriasis
Cataracts
Tuberculosis
Angina
Kidney Stones
Heart problems
Kidney disease
Swelling Ankles
Hernia
HIV/AIDS
Headaches
Numbness
Trouble Sleeping
Lupus
Urinary Tract Infection
Fibromyalgia
Arthritis
Blood Clots
Varicose Veins
Diverticulitis
PCOS
Herpes
Do you now or have you ever had: (check all that apply)
Diabetes
Heart murmur
Crohn’s disease
High blood pressure
Pneumonia
Colitis
High cholesterol
Chronic Diarrhea
Pulmonary embolism
Emphysema/Bronchitis
Anemia
Back Ache
Hypothyroidism
Asthma
Jaundice
Goiter
Emphysema
Hepatitis
Cancer (type)
Stroke
Stomach or peptic ulcer
Leukemia
Epilepsy (seizures)
Rheumatic fever
Psoriasis
Cataracts
Tuberculosis
Angina
Kidney Stones
Heart problems
Kidney disease
Swelling Ankles
Hernia
HIV/AIDS
Headaches
Numbness
Trouble Sleeping
Lupus
Urinary Tract Infection
Fibromyalgia
Arthritis
Blood Clots
Varicose Veins
Diverticulitis
PCOS
Active Infections
Arthritis
Botox/Xeomin/dysport
Chemotherapy Therapy
Laser Treatment
Cold Sores
Herbies
Dermal Fillers
Radiation
Cosmetic Plastic Surgery
Hormone Imbalance
Keloid or Hypertropic Scaring
Seizure Disorder
Skin Disorders/Skin Lesions
Rosacea
Accutane
Chemical Peels
Do you have any other health problems or medical conditions not listed above?
What type of Cancer do you have or had?
Other medical conditions (please list):
Add
Remove
Hospitalizations or Surgeries (please list):
Add
Remove
Are you currently under the care of a physician?
Yes
No
Please Explain
Are you currently under the care of a dermatologist?
Yes
No
Please Explain
Have you recently plucked, tweezed, waxed or used a hair depilatory cream?
Yes
No
Have you had any recent sun exposure, been in a tanning bed or used self-tanning cream?
Yes
No
Do you Smoke?
Yes
No
What do you smoke?
Cigarettes
Cigars
Vape Pen
Marijuana
# per day?
Do you consume alcohol?
Yes
No
If yes, # per day/week?
Have you received local anesthesia (Lidocaine/Novocain/Xylocaine) by a dentist or doctor?
Yes
No
Did you have an adverse reaction?
Yes
No
My interests or concerns:
Bio- identical Hormone Replacement
Vitamin Supplementation
Weight Loss
Wrinkles/ Creases/Folds
Body Contouring (PHYSIQ)
Sun Damage
Erectile Dysfunction (ED)
Sexual Wellness
Vaginal Laxity
Dull Lifeless Skin
Incontinence
Fuller Lips
Sagging Facial Skin
Rough Skin
Medical Grade Skin Care
Dry Skin
Fuller Cheeks
Brown Spots
Jowls/ Jowling
Appearing Tired
Brow Lift
Acne
Oily Skin
Spider Veins
Rough Skin
Crows Feet
Frown Line
Unwanted Hair
Hyperpigmentation
Smokers Lip Lines
Broken Capillaries
Are you using Contraception?
Yes
No
Are you breastfeeding?
Yes
No
During pregnancy did you develop hyperpigmentation or masking?
Yes
No
Do you have regular periods?
Yes
No
Are you going through menopause?
Yes
No
Are you receiving Hormone Replacement Therapy?
Yes
No
Where are you receiving your Hormone Replacement Therapy
Last Pap Smear:
Was it Normal?
Yes
No
If NO, please explain:
Last Mammogram:
Was it Normal?
Yes
No
If NO, please explain:
Are you still Menstruating?
Yes
No
If yes, when was your last Menstrual cycle?
Any history of Prostate problems?
Yes
No
If YES, please explain:
CURRENT MEDICATIONS
Drug allergies:
Yes
No
Please List your allergies:
Add
Remove
Current Medications
Add
Remove
What medications have you taken in the last year that you not presently taking now.
Add
Remove
Symptom Questionnaire
Progesterone
Please select a number for each symptom ranging from 0, meaning no symptoms, to 10, meaning severe symptoms, to let us know how you are feeling today.
0
1
2
3
4
5
6
7
8
9
10
Sleep Disturbances
Depression
Irritability
Anxiety
Mood Swings
Migraine Headaches
Palpitations
Estrogen
Please select a number for each symptom ranging from 0, meaning no symptoms, to 10, meaning severe symptoms, to let us know how you are feeling today.
0
1
2
3
4
5
6
7
8
9
10
Painful Intercourse
Night Sweats
Hot Flashes
Dry Skin
Chronic Fatigue
Restless Leg Syndrome
Hair Loss (Women)
Testosterone
Please select a number for each symptom ranging from 0, meaning no symptoms, to 10, meaning severe symptoms, to let us know how you are feeling today.
0
1
2
3
4
5
6
7
8
9
10
Fatigue
Weight Control
Low Sex Drive
Erectile Dysfunction
Poor Focus
Body Joint Pains
Memory Lapses
Low Exercise Tolerance
Loss of Muscle Tone
MEDICAL RECORDS RELEASE FORM
To request the release of medical information
Release my protected health information to me.
Release my protected health information to,
Name
First
Last
Phone:
Fax:
Email
If you would like the records mailed, provide the address below.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Reason for release:
Consent
I hereby authorize Renew Health and Wellness to release my medical information as requested above. This authorization will remain active for one year from date of signature, unless revoked in writing. I am aware that NSI cannot control how the recipient uses the information, and that laws protecting its confidentiality at NSI may not protect this information once it has been disclosed to the recipient. Information will not be released without a valid signature below.
Name
First
Last
Medical Record Release Consent Signature
Submission Consent
Notice of Privacy Practice
I agree to the privacy policy. Click the link to review our
privacy policy
.
Disclosures Statement
I agree to the Disclosures Statement. Click here for review our
Disclosures Statement
Consent
All Statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatment will be based on the information provided herein. If I willingly withhold knowledge from my treating physician/medical professional, I accept full liability for any consequences arising therefrom.
Aesthetics Consent
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the Esthetician, Nurse Practitioner, or Doctor of my current medical or health conditions. I agree to notify Renew of any changes in my health status.
Signature
(Required)
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