(843) 871-6944
info@medicinemansc.com
About Us
Our Services
Compounding
Free BHRT Consultations
Discounted Medications
Durable Medical Equipment
OTC Products
Free Delivery
What is BHRT?
Online Refills
Contact Us
BHRT Consultation Forms
SHIPPING AUTHORIZATION FORM
About Us
Our Services
Compounding
Free BHRT Consultations
Discounted Medications
Durable Medical Equipment
OTC Products
Free Delivery
What is BHRT?
Online Refills
Contact Us
BHRT Consultation Forms
SHIPPING AUTHORIZATION FORM
BHRT Consultation Forms
Male Questionnaire
Female Questionnaire
Male Questionnaire
Male 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 feel like the man you know you can be! The answer is Testosterone Replacement and we’re here to help you feel your best...we are just a phone call away. We recommend that you fill out our Male Health Questionnaire so that we can better assist you. You can also come into our office or call to have a
Free Consultation
with our Male Pharmacist or Registered Nurse. You took the first step… now let us do the rest!
First Name*
Last Name*
Street
City
State
Zip
Phone*
Sex*
Male
Female
Date of Birth
Age
Height
Weight
Email*
Do you drink alcohol?
Yes
No
If yes, how much?
Do you smoke?
Yes
No
If yes, how much?
Please list all Medications, Hormones & Supplements
Medication Allergies
Food Allergies
Who referred you to us?
Please list your health care provider
Date of Last Visit/Checkup
ANDROPAUSE CHECKLIST
Section I
Check All That Apply
Adult Mumps
Prostate Operation or Inflammation
Vasectomy
Orchitis or Other Testicular Problems
Persistent Urinary Infections
Section II
Check Box That Best Describes Your Symptoms
Fatigue, tiredness or loss of energy
Depression, low or negative mood
Irritability, anger, or bad temper
Anxiety or nervousness
Loss of memory or concentration
Relationship problem with partner
Loss of sex drive or Libido Erection or potency problems
Dry skin on face or hands
Excessive sweating, day or night
Backache, stiffness, joint or muscle pain
Frequent use of alcohol, past or present
Loss of physical stamina Feeling over-stressed
Loss of early morning erection
Increased fat distribution in chest area or hips
Feeling burned out, loss of motivation
Decrease in muscle mass
Increase in waist size – weight gain, especially in mid section
Female Questionnaire
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*
Male
Female
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
No
Yes
Surgery Date
Ovaries Removed
No
Yes
Surgery Date
Bilateral Tubal Ligation
No
Yes
Surgery Date
History of Endometriosis
No
Yes
History of Fibroids
No
Yes
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?
Contact Us
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