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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
Name*
MM slash DD slash YYYY
Sex*
Address*
Are you filling this form out for a minor?*
(someone under the age of 18)

Legal Guardian
Address

Ethnicity
Employment Status

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.
Past Medical History
Past Surgical History
Immunization History
List vaccine and then year.
Please list Medication, Dosage, Frequency, and Who prescribed it.
Do you currently have an intrauterine device (IUD)?
Please list Supplement, Dosage, Frequency, and Who prescribed it.
Social History
How were you delivered as a baby?*
Were you breastfed as a child for over 6 months?*
Have you taken numerous rounds of antibiotics in your life?*
Have you had past exposure to water damaged buildings containing mold?
Do you have current exposure to water damaged buildings containing mold?
Do you have history of any significant tick/bug bites?
Are you interested in IV Nutritional therapy?
Have you had any of these in the past year?
In the past 10 years?

REVIEW OF SYSTEMS

Check all that apply.
Constitutional Fevers
Head/Eyes
Ears, Nose, Throat
Cardiac
Vascular
Respiratory
Gastroinstestinal
Genitourinary
Musculoskeletal
Dermatology
Neurological
Endocrine
Hematology
Psych: How do you describe your mood?
What is the frequency of your pain?
Female
Have you had a hysterectomy?
Have you taken hormone replacement therapy (HRT)?
Please check the routes that you have taken of HRT
Are you interested in BioTe hormone pellet therapy?
Male
Are you interested in BioTe hormone pellet therapy?

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”.
Check this box if you have double checked that all relevant information has been completed and you are ready to submit the form.*

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