Symptom Survey - Hormone

Symptom Survey - Hormone

Please complete this survey to help us assess your hormone-related symptoms and medical history.
Patient Information
Date*

MonthDayYear
Date
First Name*
Middle Name
Last Name*
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid mobile number. We will text you when your prescription(s) are ready using our texting service, Nimble.Format: (000) 000-0000.
YesNo
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
SSN or DL#
The state requires this information when we fill controlled substances like Testosterone.
Drug Allergies*
If you were to list and describe your biggest, number 1 complaint(s), what would it (they) be?*
Current Menstrual Status*
YesNo
Hysterectomy - Age
Ovaries Removed
Ovaries Removed - Age
Why did you have to have a hysterectomy (and ovaries removed)?
Hormone Replacement History? Current use or History of? (Including Birth Control)
Topical Cream or Lozenge (Troche)

We usually compound hormones in the form of a topical cream and the hormones are absorbed through the skin. Or we compound hormones as a peppermint troche (“tro-key”). Troches are a gelatin type lozenge and the hormones are absorbed through the mucus membranes of the mouth. The cream comes in a Topi-Click dispenser. It looks like a deodorant dispenser. You turn/click the bottom and the cream is dispensed at the top and you can then just rub the cream onto your inner wrist/forearm or thighs (rotating sites on the thighs). The troches are dissolved under the tongue (takes about 10 minutes) and are peppermint flavored. Some women will need to take their Progesterone in the form of an oral capsule separate from their cream or troche.
Topical CreamTroche (Lozenge)
Symptom Ratings
Foggy Thinking
Hot Flashes
Night Sweats
Breasts- Tenderness
Anxious
Constipation
Hair- Increased Facial or Body
Water Retention
Swelling or Puffy Eyes/Face
Vaginal Dryness
Tearful
Fatigue- Morning
Nervous
Body Temperature Cold

Symptom Survey - Hormone

Patient Information

Symptom Ratings