New Patient

Statement of Confidentiality

I understand that this information and any future information gathered by Jill Powell, PhD, APN pertaining to my treatment is completely confidential unless I consent, in writing, to have it released to any other party.

What symptoms of menopause have you had?

List any other physicians treating you now or over the past 5 years and what you are/were treated for.

Who is your primary care physician (family doctor) or primary medical agency?

Work Phone

Home Phone

City

Dr. Jill Powell does not take insurance and patients are responsible for paying for the appointment time that is reserved for them unless that appointment has been cancelled or other arrangements have been made prior to the appointment

I understand and agree that I am responsible for the appointment times that are scheduled for me

Name

List all medications, drugs or other substances you take or have taken in the last year, to include: prescribed medications, over the counter medications, vitamins or herbs.

Address 1

How long does your period last?

How regular are your periods?

If yes, please exlpain.

How did you hear about this practice?

Social Security Number

Mobile Phone

Zip Code

Have you ever shared needles?

Have you ever injected drugs?

Have you done any kind of work where you were exposed to toxic chemicals

Do you see a therapist or counselor?

Check here to receive email updates

How heavy are your periods?

What kinds of physical exercise do you get?

Address 2

If you have started or been through menopause, at what age did it start?

Please list all pregnancies and what resulted (child born, miscarriage, abortion or any complications).

At what age did you start to menstruate (get your period)?

How much coffee, cola, tea or other sources of caffeine do you consume each day?

Date of Birth

DR. JILL POWELL

How much pain do you have during your period?

If yes, please explain.

State

Have you tested positive for HIV in the last 6 months?

If yes, who is your therapist or counselor?

List any other experiences during your period.

Emergency Contact Name and Phone Number

Do you have any problems getting enough sleep?

List all diseases, illnesses, accidents and injuries, surgeries, hospitalizations, periods of loss of consciousness, convulsions/seizures and any other medical conditions you have had.

Describe any allergies you have

Do you restrict your eating in any way? If so, how and why?

If you would be interested in becoming a patient, please complete the following new patient information and someone from my office will contact you.

New Patient Information

Are there any other medical or physical problems you are concerned about?