Register - Aspire Health

First Name

Middle Initial

Last Name

Age

Date of Birth

Occupation

Gender

Male

Female

Ethnicity

Hispanic

Not Hispanic

Unknown

Language

English

Spanish

Other

Race

White

Black

Native American

Asian

Other

Marital Status

Single

Married

Widow/Widower

Divorced

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address

Driving Licence Number

Primary Care Provider

Referring Doctor

Parent/Guardian

Note: per NC Law, Both parents can be held responsible for medical bills for minors, a medical practice is NOT bound by any separation agreement, divorce or child support order.

First Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number

Employer

Preferred Phone Number

In case of Emergency, who would you like to be contacted?

First Name

Last Name

Relationship to Patient

Home Phone Number

Work Phone Number

Medical History

Which of the following symptoms apply to you currently?

	None	Mild	Moderate	Severe	Very Severe
Hot flushes, sweating (episodes of sweating)
Heart discomfort (unusual awareness of heartbeat, heart skipping, heart racing, tightness)
Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early)
Depressive mood (feeling down, sad, lack of drive, mood swings)
Irritability (feeling nervous, inner tension, feeling aggressive)
Anxiety (inner restlessness, feeling panicky)
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
Sexual problems (change in sexual desire, in sexual activity and satisfaction)
Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
Joint and muscular discomfort (pain in the joints, rheumatoid complaints)

Which of the following symptoms apply to you currently?

	None	Mild	Moderate	Severe	Very Severe
Hot flushes, sweating (episodes of sweating)
Heart discomfort (unusual awareness of heartbeat, heart skipping, heart racing, tightness)
Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early)
Depressive mood (feeling down, sad, lack of drive, mood swings)
Irritability (feeling nervous, inner tension, feeling aggressive)
Anxiety (inner restlessness, feeling panicky)
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
Sexual problems (change in sexual desire, in sexual activity and satisfaction)
Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
Dryness of vagina (sensation of dryness or burning In the Vagina, difficulty with sexual intercourse)
Joint and muscular discomfort (pain in the joints, rheumatoid complaints)

Prior or Current Hormone Use (please list all that apply):

History of Prostate Issues

Yes

History of Heart Disease

Yes

History of Abnormal PSA Test

Yes

Date of most recent exam

History of Bone Density Issues

Yes

Have you had a Hysterectomy

Yes

What type of Hysterectomy was this

Total

Partial

Do you have regular periods

Yes

First day of last period

Hx Breast or Uterine Cancer in past 5 years

Yes

Hx Abnormal Mammogram

Yes

Date of most recent exam

Hx Abnormal Uterine Bleeding

Yes

Hx Abnormal Pap

Yes

Date of most recent exam

Hx Bone Density

Yes

Comments

Desire to have children in the future

Yes

List your prescribed drugs, over the counter medications and supplements

Name of Drug	Strength	Frequency Taken

List any medical problems that other doctors have diagnosed

Year	Medical Problem	Treatment/Medication(s): (if prescribed)

Allergies to medication:

Name of Drug	Reaction

Surgeries

Year	Type of Surgery	Surgery Reason

Hospitalizations

Year	Reaction

Family Health History: (Please comment on general, weight and psychiatric history)

All questions contained in this questionnaire are optional and will be kept strictly confidential

Father

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Mother

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Paternal Grandfather

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Paternal Grandmother

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Maternal Grandfather

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Maternal Grandmother

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Please list the ages of any children you have

Age

Health Habits

Exercise

Sedentary (no exercise)

Lightly Active (1-3 days per week)

Moderately Active (3-5 days per week)

Very Active (6-7 days per week)

How many cups of coffee do you have per day

How many cups of tea do you have per day

How many cups of Cola do you have per day

Do you drink alcohol

Yes

What kind of alcohol do you drink

How many drinks per week

Are you concerned about the amount you drink

Yes

Have you ever used Tobacco

Yes

Do you currently use tobacco

Yes

How many cigarettes per day

How many chews per day

How many pipes per day

How many cigars per day

How many years

Year quit

By signing, you agree the information above is correct and give permission for Aspire Health, PLLC to file claims on your behalf.

HIPAA CONSENT: Without signed consent, we can NOT share information regarding your medical care (including family members). Please list anyone you would like to have this information below. (leave blank if you would not like any add’l individuals to have information regarding your care.)

Contact One

Contact Two

Signature

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