Confidential Female Hormone Evaluation

Confidential Female Hormone Evaluation

Answer all questions accurately so our clinicians can make a proper assessment of your needs.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Height:
Weight
Desired Weight

	Yes	No
Do you use tobacco
Do you drink alcohol
Do you drink caffeine
Do you exercise

If you use tobacco, how often and how much do you use it?
If you drink alcohol, how often and how much do you drink?
If you drink caffeine, how often and how much do you drink?
If you exercise, how often and how much do you exercise?
Allergies: Please list any allergies and describe the reaction that occurred (Drugs, Foods and Others)
Over-the-counter medical history: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia etc..)
Current Prescription Medications (including hormones): Provide Name and strength, date started and how often you take the medicine daily
Current Prescription Medications (Including hormones): Indicate the Medication name and strength, date started, and how often you take it per day
List Hormones Previously Taken: Indicate date started, date stopped and reason for stopping
Have you ever used oral contraceptives (birth control)?
If you experienced any problems while using birth control, please describe:
How many pregnancies have you had?
How many children have you had?
Have you had any interrupted pregnancies?
If Yes, please explain:
Have you had a tubal ligation or hysterectomy?
If you have had a hysterectomy, provide reason.
If you have had a hysterectomy, do your ovaries remain?
Do you have a family history of any cancers or osteoporosis?
List any family members with cancers or osteoporosis

Have you had any of the following tests performed?

	Yes	No
Mammography
PAP Smear
Bone Density

Provide Dates and Outcome results for the Mammograph, PAP Smear and Bone Density tests
At what age did your period start?
How many days is/was your cycle (example: 28 days)
Is/was your menstrual flow heavy or light?
Any Clots?
Have you ever had what YOU would consider to be abnormal cycles?
Explain
When was your last period?
How many days did it last?
Do you or have you suffered from Premenstrual Syndrome (PMS) symptoms?
Explain

Answer each of the following:

	Absent	Mild	Moderate	Severe
Hot Flashes
Night Sweats
Vaginal Dryness
Incontinence
Bleeding Changes
Fibrocystic Breast
Weight Gain
Fluid Retention
Dry Skin/Hair
Hair Loss
Anxiety
Depression
Mood Swings
Irritability
Headaches
Breast Tenderness
Cramps
Difficulty Falling Asleep
Difficulty Staying Asleep
Fatigue
Loss of Memory
Foggy Thinking
Acne
Arthritis
Decreased Sex Drive
Harder to Reach Climax
Stress

Other:
My Purchase(s)
prevnext( X )
Initial Assessment with FeedbackOne of our clinicians will review your form and provide you with a preliminary professional assessment of your unique condition along with recommendations.
$25.00

Comprehensive Assessment with Lab TestingIn addition to the preliminary assessment of your questionnaire, one of our clinicians will provide a lab test to further confirm results and identify underlying causes. The results of the lab tests will be reviewed with you on a 25-minute phone or Zoom call ($150 value).
$325.00

Total

$0.00
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