All questions contained in this questionnaire are strictly confidential.

Please review our policies on making recommendations in the “Getting Started” section located in the Resources tab on our website.

Contact Information

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* Contact Information

Phone Number(s)

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* Phone Number(s)

Date of Birth

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* Date of Birth

Date of Birth
Allergies to medications or Foods (Drug/Food name & reaction experienced)

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* Allergies to medications or Foods (Drug/Food name & reaction experienced)

Height (in)

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* Height (in)

Weight (lbs)

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* Weight (lbs)

Do you have prescription drug insurance?

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* Do you have prescription drug insurance?

Insurance Company

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* Insurance Company

Insurance ID#

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* Insurance ID#

Rx Group #

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* Rx Group #

Rx Bin #

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* Rx Bin #

Doctor's Name

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* Doctor's Name

Doctor's Phone

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* Doctor's Phone

What are your main reasons for seeking care?

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* What are your main reasons for seeking care?

Are you taking hormones? If so what is your regimen?

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* Are you taking hormones? If so what is your regimen?

List any previous hormone therapy you have tried:

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* List any previous hormone therapy you have tried:

List your prescribed drugs and over-the-counter drugs, such as vitamins, nutritional or natural products you are currently taking:

Question Title

* List your prescribed drugs and over-the-counter drugs, such as vitamins, nutritional or natural products you are currently taking:

SURGERY AND MEDICAL HISTORY
All questions contained in this questionnaire are optional and will be kept strictly confidential.
Have you had any of the following surgeries?

Question Title

* Have you had any of the following surgeries?

Hysterectomy Date (If Applicable)

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* Hysterectomy Date (If Applicable)

Date
Ovary Removal Date (If applicable)

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* Ovary Removal Date (If applicable)

Date
Ablation Date (If applicable)

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* Ablation Date (If applicable)

Date
Check any of the following conditions you have had previously or currently:

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* Check any of the following conditions you have had previously or currently:

Is there a family history of…?

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* Is there a family history of…?

If you have a family history of above, what's their relation to you?

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* If you have a family history of above, what's their relation to you?

Do you still have your period?

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* Do you still have your period?

If you still have regular periods, what was the date of your last period?

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* If you still have regular periods, what was the date of your last period?

Date
Have you had a mammogram?

Question Title

* Have you had a mammogram?

If you have had a mammogram, within the last 12 months, when was the date? (If you have not had a mammogram and need to bypass this question, please indicate field with date of 01/01/1900.)

Question Title

* If you have had a mammogram, within the last 12 months, when was the date? (If you have not had a mammogram and need to bypass this question, please indicate field with date of 01/01/1900.)

Date
Have you had a bone density test within the last 3 years?

Question Title

* Have you had a bone density test within the last 3 years?

Do you or did you have PMS or PMDD?

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* Do you or did you have PMS or PMDD?

Do you have cramps?

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* Do you have cramps?

Have you ever taken birth control pills?

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* Have you ever taken birth control pills?

If yes, which one?

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* If yes, which one?

Do you use alcohol? If yes how much?

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* Do you use alcohol? If yes how much?

RATE THE FOLLOWING IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS RECENTLY.

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* RATE THE FOLLOWING IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS RECENTLY.

  0 None 1 Mild 3 Moderate 4 Severe
Sleep disruption/Insomnia
Decreased libido (sex drive)
Night sweats
Depression
Fluid retention
Vaginal dryness
Migraines/headaches
Irritability
New facial hair
Nervousness/anxiety
Decreased quality of orgasm or intercourse
Hot flashes
Breast tenderness
Dry skin
Mood swings
Crying easily
Weight gain
Short term memory loss
Painful intercourse
Poor concentration
Food cravings
Backaches
Hair loss
Fatigue
Acne
Oily skin
Dry eyes
Decreased muscle mass
Bleeding changes or disorders
Heart palpitations
Brittle or breaking nails
Thinning of skin
Do you use tobacco products?

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* Do you use tobacco products?

Do you get physical exercise? If yes, what type and how often?

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* Do you get physical exercise? If yes, what type and how often?

Do you have any questions, comments or concerns regarding Natural Hormone Replacement Therapy?

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* Do you have any questions, comments or concerns regarding Natural Hormone Replacement Therapy?

How did you hear about us?

Question Title

* How did you hear about us?

 
100% of survey complete.

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