Sign-up form

Please complete the questions below to help us match you to a group or clinician from Bia Care's menopause clinic.

Any information you share with us is confidential and we won't share it with 3rd parties.

Please feel free to email us at: hello@bia.care or fernanda@bia.care if you have any further questions.

Personal

Medical history

Do you have a personal history of any of the following?

Please check all that apply

Have you had any of the following surgeries?

Please check all that apply

Do you have a history of autoimmune conditions?

If yes, please describe:

Do you have a personal history of any of the following heart conditions?

Please check all that apply

Do you have a personal history of any of the following cancer(s)?

Please check all that apply

What other medical conditions do you have, if any?

If none, provide anything else you would like to mention

Medications

Are you using any of the following hormonal medications?

Please check all that apply

Please list any medication you are currently taking or have taken in the last 12 months, if any?

Please list the dose of your medication and how often you are taking it.

What over-the-counter medication, vitamins or supplements are you taking, if any?

When was your last menstrual period?

Give approximate date if actual date not known

Have you had any abnormal vaginal bleeding? For example, after sex, between periods or especially heavy periods.

If yes, please describe as fully as possible:

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