Female Health Questionnaire

Bio-Identical Hormone Replacement Therapy


We’re so glad you found us on the internet and we would love the opportunity to help you in your journey to Hormonal Balance and a Happier, Healthier you! To better assist you we recommend you fill out our Female Health Questionnaire, so that we can better serve you. You can also come into our office or call to have a free consultation with our staff Registered Nurse. Hormonal Balance can improve your quality of life…so don’t delay we’re just a phone call away!

 
First Name*
Last Name*
Street
City
State
Zip
Phone*
Sex*
MaleFemale
Date of Birth

Age*
Height
Weight
Email*
Please list all Medications, Hormones & Supplements
Medication Allergies
Primary Doctor's Name
Primary Doctor's Address
Primary Doctor's Phone
Date of Last Checkup
Papsmear Date
Mammogram Date
Last Menstrual Period
Hysterectomy
NoYes
Surgery Date
 
Ovaries Removed
NoYes
Surgery Date
 
 
Bilateral Tubal Ligation
NoYes
Surgery Date
 
 
History of Endometriosis
NoYes
History of Fibroids
NoYes
 
 
History of Polycystic Ovary Syndrome (PCOS)?
History of Abnormal Papsmear?
History of Female Organ Cancer>
History of Blood Clots (DVT, Pulmonary Embolism?)
How did you hear about us?
 
 
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