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Hormone Consults Private
Hormone Consults Private
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Today's Date
*
dd/mm/yyyy
Name
*
First
Last
Date of Birth
*
dd/mm/yyyy
Current Weight
*
in pounds
Current Height
*
in ft + inches, ex: 5'4"
Address
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Address Line 1
Address Line 2
City
--- Select state ---
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District of Columbia
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Pennsylvania
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South Carolina
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Tennessee
Texas
Utah
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Washington
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Wisconsin
Wyoming
State
Zip Code
Email
*
Phone
*
Additional Information
Occupation
Did your physician recommend you to us?
*
Yes
No
Physician's Name
What are your greatest needs that you hope to solve with us?
List your current medical conditions
List any medication allergies
List any allergies to foods, pollen, etc..
List any prescription meds taken in the last 6 months
List all supplements, vitamins, non-prescription meds, or other OTC products that you are currently taking
Have you had a bone density test? If so, what were your results?
Stress Level 1-10
Selected Value:
0
Rate your stress level 0-10 where 0=no stress and 10="you will not believe my stress level!"
How many ounces of water do you drink in 24 hours?
Any dietary restrictions?
Last medical exam
mm/dd/yyyy
Do you still have menstrual periods? If so, when was your last one?
If still having periods, tell us about them: cramping, or unusual bleeding?
Tell us anything you feel is a concern regarding your periods.
If you no longer have periods, how they were when you did have them?
PMS, ever had symptoms of this? Is so please tell us about your PMS experience.
Have you had a hysterectomy? If yes, when?
Has your doctor diagnosed you as menopausal?
How many times have you been pregnant?
How many pregnancies resulted in live births?
Any miscarriages?
Current birth control method:
Date of last mammogram
Results of your most recent mammogram
Have you experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant?
Hot Flashes
*
I don't have these
Mild
Moderate
Severe
Night Sweats
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I don't have these
Mild
Moderate
Severe
Brain Fog
*
I don't have this
Mild
Moderate
Severe
us If mammogram
Trouble Sleeping
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I don't have this
Mild
Moderate
Severe
Unusual Tiredness
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I don't have this
Mild
Moderate
Severe
Irritability
*
I don't have this
Mild
Moderate
Severe
Depression
*
I don't have this
Mild
Moderate
Severe
Anxiety
*
I don't have this
Mild
Moderate
Severe
Mood swings or changes
*
I don't have this
Mild
Moderate
Severe
Crying easily
*
I don't have this
Mild
Moderate
Severe
Tightness in neck and/or shoulders
*
I don't have this
Mild
Moderate
Severe
Backache
*
I don't have this
Mild
Moderate
Severe
Joint pains
*
I don't have this
Mild
Moderate
Severe
Muscle pains
*
I don't have this
Mild
Moderate
Severe
Skin hurts to be touched
*
I don't have this
Mild
Moderate
Severe
Acne
*
I don't have this
Mild
Moderate
Severe
New facial hair
*
I don't have this
Mild
Moderate
Severe
Dry skin
*
I don't have this
Mild
Moderate
Severe
Dry hair
*
I don't have this
Mild
Moderate
Severe
Brittle nails
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I don't have this
Mild
Moderate
Severe
Frequent Urinary Tract Infections
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I don't have this
Mild
Moderate
Severe
Vaginal dryness
*
I don't have this
Mild
Moderate
Severe
Vaginal tissue thinning
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I don't have this
Mild
Moderate
Severe
Uncomfortable intercourse
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I don't have this
Mild
Moderate
Severe
Difficulty having orgasms
*
I don't have this
Mild
Moderate
Severe
Loss of sexual sensitivity
*
I don't have this
Mild
Moderate
Severe
Loss of sexual desire
*
I don't have this
Mild
Moderate
Severe
Breast or nipple sensitivity
*
I don't have this
Mild
Moderate
Severe
Breast cysts
*
I don't have this
Mild
Moderate
Severe
Family history of breast cancer
*
I don't have this
Mild
Moderate
Severe
Food cravings
*
I don't have this
Mild
Moderate
Severe
Unexplained weight gain
*
I don't have this
Mild
Moderate
Severe
Unexplained weight loss
*
I don't have this
Mild
Moderate
Severe
Hair loss
*
I don't have this
Mild
Moderate
Severe
Submit
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