Vitality Health Coaching Intake Form • Solutions Clinical Pharmacy

(403) 528-3900
(403) 487-3901

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Solutions Clinical Pharmacy

Vitality Health Coaching Intake Form

Vitality Coaching Program: 30-minute consultation once a week. This program starts at $497 per month, with a minimum commitment of 4 months.

If you have completed an initial consult, your initial intake appointment is applied to the cost.

"*" indicates required fields

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Name

First Last

Email*

Phone*

Birth Date*

MM slash DD slash YYYY

Height*

Weight*

Alberta Health Care Number*

Allergies*

Please list any Medication, Food or Environmental allergies you have and your reactions.

Current Medications*

Vitamins, herbs, dietary or nutritional supplements:

Which hormone service are you interested in?*

Vitality Coaching Program

Hormone Advising

Current Hormones

Estrogen

Include dose and frequency:

Progesterone

Include dose and frequency:

Testosterone

Include dose and frequency:

DHEA

Include dose and frequency:

Pregnenolone

Include dose and frequency:

Other

Include dose and frequency:

Have you tried any hormones that have not worked for you?*

Yes

No

If yes, please list:*

Patient History

Do you have a history of the following:*

Breast cancer

Uterine cancer

Stroke

Clots in legs of lungs

Diabetes

High blood pressure

Irregular heart beat

Heart attack

None

What symptoms are you trying to address:*

Hot flashes

Mood swings

Night sweats

Hair loss

Skin aging

Fatigue/low energy

Depression

Vaginal dryness/painful intercourse

Weight gain

Memory/mental “fog”

Decreased muscle mass

Low libido

None

Are you a smoker?*

Yes

No

Who is your Family Doctor:*

Have you had previous Rocky Mountain Analytical Testing?

If so, please attach test results.

Max. file size: 8 MB.

Gynecological History

Have you had your ovaries removed?

Please include date.

Have you had a hysterectomy?

Please include date.

Have you had a tubal ligation?

Please include date.

Are you in menopause?*

Yes

No

Age at Menopause:*

Check any that apply:*

Fibrocystic breasts

Endometriosis

Fibroids

Heavy periods

Painful periods

PMS

Spotting

Vaginal discharge

None

What have been the major causes of stress/worry/anxiety/frustration in you life in the past?*

What have been the major causes of stress/worry/anxiety/frustration in you life now?*

Describe your usual energy levels most days. Does your energy fluctuate through the day?*

What are your general sleep habits? Do you have trouble falling asleep or staying asleep, do you awaken at night, snore, feel groggy upon waking?*

What time do you go to bed?*

Hours

:

Minutes

AM/PM

What time do you fall asleep?*

Hours

:

Minutes

AM/PM

How many hours per night do you sleep?*

How did you hear about us?*

Did you receive a referral for our hormone services?

North Location

#200 511 4 Avenue NE
Medicine Hat AB T1A 6B3

Tel: (403) 487-3901
Fax: (403) 487-3903

South Location

#1 – 2020 Strachan Road SE
Medicine Hat, AB T1B 0M9

Tel: (403) 528-3900
Fax: (403) 528-3993

Hours

Monday – Thursday 9AM – 6PM

Friday 9AM – 3PM

Saturday 9AM – 3PM

Sunday and Holidays CLOSED

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