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Women Health MIF

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

First Name*
Last Name*
Phone Number*
Email*
Address*
City*
State Of Residence*
Zip Code*
Height*
Weight*
What is your date of birth?*
Gender* Female Male
Current Medical Problems: (Please list in space below. If no medical problems then enter NONE.)*
Prior Surgeries: (Please list in space below. If no surgeries then enter NONE.)*
Prior Hospitalizations: (Please list in space below. If no hospitalizations then enter NONE.)*

Current Medications, Supplements, Herbal, and OTC’s.

Name* Dosage* Frequency*

Health Habits & Personal Safety (circle yes or no)

Do you exercise? *


Are you currently dieting?*

Caffeine Intake: *


Alcohol Intake:*


Tobacco use:*


Are you sexually active*


Are you trying to get pregnant?*


If not, are you using birth control?*


Do you experience discomfort during intercourse?*


Are you HIV+ or do you have AIDS?*


Family Health History

Family Member Age or Age at Death Medical Problems
Grandparents:*
Father:*
Mother:*
Brothers:*
Sisters:*

Menstrual, Pregnancy, & Gynecological History

Age at menstruation onset:*
Date of last period:*
How many days between each period?*
Menstruation duration: (Days)*
Number of pregnancies:*
Number of live births:*
Do you have heavy or irregular periods?*


Do you have spotting between periods?*


Are you:*




Do you have vaginal pain or unusual discharge?*


Are you pregnant or breastfeeding?*


Have you had a D&C, cesarean, or hysterectomy?*


When was your last gynecologist visit?*
When was your last pap smear?*
When was your last mammogram?*
Do you have pain during intercourse?*


Do you have vaginal dryness?*


Have you ever had breast cancer?*


Have you ever had thyroid cancer?*


Have you ever had ovarian cancer?*


Mental Status

Have you recently had concentration difficulties*


Have you recently had mood swings*


Have you recently had an increased sense of stress*


Have you recently had any decreased motivation*


Have you recently been feeling depressed*


Have you recently had any difficulty sleeping*


Have you recently noticed decreased energy*


Have you recently been exercising less*


Have you recently had a decrease in muscle strength*


Have you recently had a decreased libido/sex drive*


Have you recently had feelings of fatigue or lethargy*


Have you recently had decreased sociability*


Have you recently noticed short term memory issues*


Have you recently noticed long term memory issues*


Have you recently noticed decreased self confidence*


Have you recently noticed decreased sense of well-being*


Other (Have you had or noticed any of the following)

Decreased skin elasticity*


Arthritis*


Decreased sex drive*


Body aches & pains*


Decreased endurance*


Scars, or skin marks*


Increased exercise healing time*


Migraines*


Decreased skin tone*


Open wounds*


Decreased muscle mass*


Nerve pain or inflammation*


Tendonitis*


Skin allergy*


Headaches*


Shingles*


Susceptibility to sports injuries*


Osteoporosis*


Increased nipple sensitivity*


Increasing back pain*


Recent menstrual changes*


Muscle aches & pains*


Thinning or loss of hair*


Aching/stiff joints in the morning*


Poor/slow wound healing*


Have you ever been prescribed any type of hormone therapy? If yes, explain in detail your treatment if possible.*
Have you ever been on a HGH or similar program? If yes, explain in detail your treatment if possible.*

Additional Information

Emergency Contact Name
Emergency Contact Phone
Relationship Status
Occupation
We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Date : 09/26/2020

Note: Your medical information will not be saved until you click on the SUBMIT button.