All questions contained in this questionnaire are strictly confidential.

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* 1. Contact Information

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* 2. Phone Number(s)

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* 3. Date of Birth

Date of Birth

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

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* 5. Height (in)

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* 6. Weight (lbs)

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* 7. Do you have prescription drug insurance?

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* 8. Insurance Company

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* 9. Insurance ID#

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* 10. Rx Group #

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* 11. Rx Bin #

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* 12. Doctor's Name

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* 13. Doctor's Phone

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* 14. What are your main reasons for seeking care?

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

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* 16. List any previous hormone therapy you have tried:

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* 17. 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.

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* 18. Have you had any of the following surgeries?

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

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* 20. Is there a family history of…?

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* 21. Do you use tobacco products?

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* 22. If you smoke is your doctor aware?

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* 23. If you have any questions please ask them here:

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* 24. 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)
Weakness
Depression
Fatigue
Erectile Dysfunction
Slow wound healing
Reduced muscle mass
Irritability
Nervousness/anxiety
Mood Swings
Weight Gain
Short term memory loss
Other

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* 25. Where did you hear about us?

 
100% of survey complete.

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