• Date of Birth*
     - -
  • What was your gender at birth?*

  • This visit is NOT intended for individuals under 19 years of age. Please discontinue the visit. 

  • This visit is intended for individuals born with the female gender. If you are male, please discontinue this visit and select the Male Hormone Visit. 


  •
  • Format: (000) 000-0000.

  • TERMS OF SERVICE

  • *

  • Advanced Beneficiary Notice

    Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor. 

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*
  • Please select which type visit this is for:
  • Are your current hormone prescription(s) from us (Omnia Telehealth)?*

  • Hormone Related Symptoms

    Current Symptoms - Select the severity of symptoms that apply to you
  • Rows

  • Family Medical History

  • Any change in family history since your last visit?*
  • Rows

  • GYNECOLOGICAL HISTORY

  • Have you had a hysterectomy?*
  • Did you have a complete or partial hysterectomy?*
  • Do you still have your ovaries?*
  • Have you had an endometrial ablation?*
  • Do you still have menstrual cycles?*
  • Do you have regular menstrual cycles?*
  • How many days do your cycles last?*
  • Are your cycles heavy?*
  • Do you have bleeding between periods?*
  • Do you have menstrual cramps?*
  • How would you describe your menstrual cramps?*
  • Do you get PMS symptoms?*
  • When was your last menstrual cycle? (Select the date for day 1 of menstruation)*
     - -

  • Personal Medical History

  • Have you ever been diagnosed with any of the following? (Select ALL that apply)*
  • Have you had a hemoglobin A1C taken in the last 6 months?*
  • Please select the HgbA1c range that accurately reflects your result.*
  • Which type of thyroid disease have you been diagnosed with?*
  • Are you currently being treated for the cancer?*
  • Have you ever been diagnosed with Polycystic Ovary Syndrome (PCOS)?*

  • Obstetric History

  • Are there any changes in your obstetric history since your last visit?*
  • Have you ever been pregnant?*
  • Have you ever had a miscarriage?*

  • PERSONAL MEDICAL HISTORY

  • Have you ever had surgery?*
  • When was your last physical exam?*
  • Were there any abnormal findings on your last physical exam?
  • Have you ever had any of the following cardiac testing? (Select ALL that apply)*
  • Were there any abnormal findings on the electrocardiogram (EKG)?*
  • Were there any abnormal findings on the echocardiogram (Echo)?*
  • Were there any abnormal findings on the Stress Test?*

  • Medical History

    Routine Screenings
  • Have you ever had a gynecological exam/pap smear?*
  • When was your last gynecological exam/pap smear?*
  • Was the gynecological exam/pap smear normal?*
  • Have you ever had a bone density (DEXA) scan?
  • When was your last bone density (DEXA) scan?*
  • What were the results/findings on your bone density (DEXA) scan?*
  • Have you ever had a mammogram?
  • When was your last mammogram?*
  • Were your mammogram results normal?
  • Have you ever had a colonoscopy?*
  • When was your last colonoscopy?*
  • Were there any abnormal findings on your colonoscopy?*

  • Social History

  • Do you exercise?*
  • How many days per week do you exercise?*
  • What do you do for exercise? (Select ALL that apply)*
  • How long have you been exercising for?*
  • Do you consume alcohol?
  • How often do you consume alcohol?*
  • On average, how many alcoholic drinks do you consume per day?*
  • Do you smoke?*
  • What type substance do you smoke? (Select ALL that apply)*
  • Do you experience excessive stress?

  • Medication History

    Hormones
  • Have you ever taken hormones of any kind (birth control pills, HRT, or natural hormones)?*
  • Are you currently taking hormones of any kind (birth control pills, HRT, or natural hormones)?*
  • Are you experiencing any adverse side effects from the hormones you are currently taking?*

  • Medication Refill Information

  • Are you currently experiencing any adverse side effects related to this medication?
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  • Medication History

  • Have you been told by a provider to avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen for pain relief?*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*

  • Pregnancy and Breastfeeding

  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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