BHRT Consultation Forms

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!

     
    Sex*
    Do you drink alcohol?
    Do you smoke?
     
     
     
     

    ANDROPAUSE CHECKLIST

     

    Section I

     
    Check All That Apply
     

    Section II

     
    Check Box That Best Describes Your Symptoms
     
     
    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!

       
      Sex*
       
      Hysterectomy
      Ovaries Removed
      Bilateral Tubal Ligation
      History of Endometriosis
      History of Fibroids
       
       
       
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