Today's Date: *
Name: *
Street Address: *
City, State and Zip Code: *
Phone Number: *
Email Address: *
Date of Birth: *
Age: *
Height: *
Weight: *
Do you use tabacco? *
Yes
No
If you checked yes above, how often do you use tabacco?
Do you use alcohol? *
Yes
No
If you checked yes above, how often do you use alcohol?
Do you use caffeine? *
Yes
No
If you checked yes above, how often do you use caffeine?
Doctor's Name: *
Doctor's Street Address: *
Doctor's City and Zip Code: *
Do you have any known allergies? *
Yes
No
Describe your allergic reactions and when they occured?
Are you currently taking any over the counter medications? *
Yes
No
Are you currently taking any nutritional or natural supplements? *
Yes
No
Please list all OTC/nutritional supplements and dosages: *
Please list all prescribed medications name, strength, date started and how often used: *
Please list any personal medical history conditions and/or diseases: *
Please provide any hormones previously taken: *
Between what date's did you take these hormones? *
What was the reason for taking these hormones? *
Have you ever used oral contraceptives? *
Yes
No
If you had any problems with oral contraceptives please describe:
How many pregnancies have you had? *
Any interrupted pregnancies? *
Yes
No
Have you had any hysterectomy (date of surgery)? *
Ovaries removed: *
Yes
No
Have you had a tubal ligation (date)? *
Date of last mammography? *
Date of last PAP smear? *
Since beginning your periods, have you had what you would consider abnormal cycles?
Yes
No
Please explain:
When was your last period? *
How many days did it last? *
Do you have, or did you have Premenstral Syndrome (PMS)?
Yes
No
If yes, please explain:
How would you prefer to take your customized horomone replacement therapy? *
How did you decide to consider customized hormone replacement therapy?
What are your goals for taking customized hormone replacement therapy? *
Do you have any questions about customized hormone replacement therapy? *
Choose all that Apply to your family history: *
Uterine Cancer
Ovarian Cancer
Fibercystic Breast
Breast Cancer
Heart Disease
Osteoporosis
What family member?
Please list all symptoms (ot flashes, night sweats, fatigue, etc) you are currently having: