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Integrative Health and Hormone Clinic
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NEW PATIENT
Integrative Health and Hormone Clinic
Menu
  • About
    • About Us
    • Dr. Stephanie Gray
    • Our Staff
    • Testimonials
    • Clinic Pictures
    • Home
    • Close
  • Health Services
    • General
    • Laboratory Testing
    • IV Nutrition
    • Hormones
    • Health Coaching
    • Thermography
    • Skin Care
    • Florida Residents Telehealth
    • Close
  • Patients
    • Start Here
    • New Patient Paperwork
    • FAQ
    • Test Kit Instructions
    • Patient Portal
    • Close
  • Resources
    • The Doctor’s Desk
    • Press/Media – Dr. Gray’s up-to-date media page with podcasts, news interviews, and articles.
    • Your Longevity Blueprint – Dr. Gray’s new book!
    • Podcast
    • Healthy Recipes
    • Community Links
    • Bonuses
    • Close
  • Store

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  • 1731 Boyson Road, Hiawatha, IA 52233
    (319) 363-0033

  • DEMOGRAPHIC PROFILE

    Please complete to the best of your knowledge.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • (someone under the age of 18)


  • COMPREHENSIVE HEALTH INFORMATION

  • (If recommended by a current patient, please state who so we can send them a token of our appreciation!)
  • When listing your history below, please prioritize and score their severity on a scale of 0-10 with 0 being non-bothersome and 10 being the worst imaginable. We may not have time to discuss everything in the first visit so prioritizing will assist us in addressing your most important issues during your initial visit. Please list in this format: Illness | Score | Approximate time it started Use a new line for each illness.
  • List vaccine and then year.
  • Please list Medication, Dosage, Frequency, and Who prescribed it.
  • Please list Supplement, Dosage, Frequency, and Who prescribed it.
  • REVIEW OF SYSTEMS

    Check all that apply.
  • FAMILY MEDICAL HISTORY

    List any family relations that have had a history of the diseases below. For example, if your grandmother on your mother’s side had diabetes, find diabetes in the list below, then click on "Choose One" and then select “Maternal Grandmother”.

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