Dr Victoria Andarcia, MD

Physician

Menopause Renaissance Application

The Menopause Renaissance is a 12-month, immersive program designed for women who are ready to approach perimenopause/menopause as a turning point for long-term strength, vitality, and confidence. This application helps us understand whether this program is the right fit for you and ensures that everyone who joins is aligned with the commitment and philosophy of the experience.

Patient Information

Legal First Name

Last Name

Preferred first name

Middle name

Address

Street Address

City

State

Country

Enter your country

Postal Code

Phone *

Email *

Date of birth

Relationship Status

Gender Preference

Occupation

Hours per week

Medical History

Primary Care Physician

Title

Physician's First Name

Physician's Last Name

Title/Occupation

Physician's Address

Work Phone

Mobile Phone

Fax Number

Current Medications

Allergies

Past Medical History

Hypertension

Heart Disease

Cancer

Diabetes

Osteoporosis

Other

Surgical History

Menstrual History

Age at Menarche

Menstrual Cycle Regularity

Regular

Irregular

Not Applicable

Last menstrual period (LMP)

Menstrual Symptoms

Heavy Bleeding

Mood Changes

Breast Tenderness

Painful Periods

Acne

Other

Menopause Symptoms

Are you currently experiencing any of the following symptoms?

Hot Flashes

Sleep Disturbances

Vaginal Dryness

Memory Issues/Brain Fog

Other

Night Sweats

Mood Swings

Decreased Libido

Joint Pain

When did you first notice these symptoms?

Which areas feel most affected right now?

Energy and stamina

Bone health or fear of fractures

Mood or emotional resilience

Weight or body composition

Strength or muscle tone

Brain fog, focus, or anxiety

Sexual wellness or intimacy

Cardiovascular or metabolic health

Severity of Symptoms

Lifestyle and Health Habits

Exercise Frequency

Alcohol Consumption

Tobacco Use

Previous Treatments

Have you previously sought treatment for menopause symptoms?

What treatments have you tried?

What has felt most frustrating or disappointing about the care you’ve received so far (if any)?

Goals and Expectations

What are your primary goals for seeking treatment?

The Menopause Renaissance is a 12-month program focused on prevention, accountability, and long-term outcomes—not quick fixes. Does this align with what you’re looking for?

This program requires active participation, follow-through on testing, and engagement throughout the year. Are you ready to commit to that level of involvement?

Final Reflection

Why do you feel now is the right time to invest in yourself and your long-term health?

Consent and Acknowledgment

I acknowledge that the information provided is accurate to the best of my knowledge. I consent to the use of this information for my treatment and understand my rights regarding privacy and confidentiality.

Signature

Clear