HRT Online Assessment

Hormone Replacement Therapy Assessment

Please fill out the following medical assessment as honestly and accurately as possible. This questionnaire helps us personalize your experience and determine your best course of treatment. It will take about 5 minutes. Your privacy is important to us, any information you provide is secure.

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Today's Date

YearMonthDay
Date of Submission
There was a time in my life when I felt better than I do now.*

YesNo
What is the best possible outcome for you if you're able to alleviate your symptoms?*

Physically feeling betterMentally feeling betterLooking youngerJust feeling like myself againOther

Do any of the following apply to you?
- Severe Liver Disease or Liver Failure
- Hormone Positive Breast Cancer in the last 5 years
- Acute Cerebrovascular Accident (CVA)
- Myocardial Infarction (MI)
- Pulmonary Embolism (PE)
- Deep Vein Thrombosis (DVT)
- Currently Pregnant or trying to become Pregnant
Please select your answer below:*

Yes, one or more of the above conditions apply to meNo, none of the above conditions apply to me

Unfortunately, you are not a candidate for Hormone Replacement Therapy.
While you may not be a candidate for Hormone Replacement Therapy, we offer a wide variety of treatments that may be beneficial for you.

Give us a call at 817-720-6320 if you have any questions or would like to schedule a consultation.

You may also book online using our convenient online portal.

CLICK HERE TO BOOK ONLINE!

Are you biologically male or female?*

MaleFemale