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!

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

Age
Height
Weight
Email*
Do you drink alcohol?
If yes, how much?
Do you smoke?
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 MumpsProstate Operation or InflammationVasectomyOrchitis or Other Testicular ProblemsPersistent Urinary Infections
 

Section II

 
Check Box That Best Describes Your Symptoms
Fatigue, tiredness or loss of energyDepression, low or negative moodIrritability, anger, or bad temperAnxiety or nervousnessLoss of memory or concentrationRelationship problem with partnerLoss of sex drive or LibidoErection or potency problemsDry skin on face or handsExcessive sweating, day or nightBackache, stiffness, joint or muscle painFrequent use of alcohol, past or presentLoss of physical staminaFeeling over-stressedLoss of early morning erectionIncreased fat distribution in chest area or hipsFeeling burned out, loss of motivationDecrease in muscle massIncrease in waist size – weight gain, especially in mid section
 
[recaptcha]
 
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*
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?
 
 
[recaptcha]
 
Contact Us