Please submit the requested information below and a compounding pharmacist will contact you to arrange a personal consultation appointment. The form may take up to 40 minutes to complete. Hormone and Wellness Consultations are 150$.

Today's Date *
Today's Date
Contact Information
Name *
Name
Address *
Address
Home Phone *
Home Phone
Work Phone
Work Phone
Fax
Fax
About You
Birthdate *
Birthdate
List the most important; then list other issues in order of importance.
Medical History
Examples: Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc.
OTC = over the counter medications
Such as salt, carbohydrates, milk products, red meats, etc.
When was your last general medical exam?
When was your last general medical exam?
When was your last pelvic exam?
When was your last pelvic exam?
Menstrual History
Surgical History
Pregnancy History
Birth Control History
Have you ever used any of the following birth control methods:
Mammary History
Symptoms Evaluation
Check a box for each symptom which best describes how you have been feeling for the past 4 weeks.
One or more of the following questions may be repeated in another section of this survey. Please answer all questions as each section pertains to different things. Thank you.
Hot Flashes (daytime) *
Night Sweats *
Vaginal Dryness *
Incontinence *
Bleeding Changes *
Uterine Fibroids *
Water Retention *
Breast Tenderness *
Fibrocystic Breast *
Increased Forgetfulness *
Foggy Thinking *
Tearful *
Depressed *
Mood Swings *
Evening Fatigue *
Difficulty Sleeping *
Decreased Stamina *
Anxiety *
Irritability *
Nervousness *
Fibromyalgia *
Allergies *
Headaches *
Sugar Cravings *
Dizziness *
Cold Body Temperature *
Goiter *
Hoarseness *
Dry or Brittle Hair *
Brittle or Breaking Nails *
Constipation *
Slow Pulse Rate *
Rapid Heartbeat *
Heart Palpitations *
Infertility Problems *
Acne *
Increased Facial or Body Hair *
Scalp Hair Loss *
Weight Gain in Hips *
Weight Gain in Waist *
High Cholesterol *
Elevated Triglycerides *
Decreased Libido *
Decreased Muscle Size *
Ringing in the Ears *
Rapid Aging *
Aches and Pains *
Bone Loss *
Panic Attacks *
ADD/ADHD *
Compulsions/Addictions *
Thyroid Evaluation
Check a box for each symptom which best describes how you have been feeling for the past 4 weeks.
One or more of the following questions may be repeated in another section of this survey. Please answer all questions as each section pertains to different things. Thank you.
Depression *
Weight Gain *
Cold Extremities *
Cold Intolerance *
Feel Chilly *
Dry Hair *
Brittle Hair *
Dry Skin *
Eczema *
Acne *
Puffy Eyelids / Face *
Brittle Nails *
Difficult Menses *
Constipation *
Mentally Sluggish *
Headache *
Insomnia *
Early Morning Fatigue *
Late Morning Fatigue *
Muscle Cramps *
Low Sex Drive *
(Goiter, Hypothyroidism, Hyperthyroidism, Graves Disease, Hashimoto's Disease, etc.)
Adrenal Evaluation
Check a box for each symptom which best describes how you have been feeling for the past 4 weeks.
One or more of the following questions may be repeated in another section of this survey. Please answer all questions as each section pertains to different things. Thank you.
I have not felt well since:
I have not felt well since:
(describe event, if any)
Predisposing Factors
I have experienced long periods of stress that have affected my well being. *
I have had one or more severly stressful events that have affected my well being. *
I have driven myself to exhaustion. *
I overwork with little play or relaxation for extended periods. *
I have extended, severe or recurring respiratory infections. *
I have taken long term or intense steroid therapy. *
I tend to gain weight, especially around the middle. *
(muffin top/spare tire)
I have a history of alcoholism and/or drug abuse. *
I have environmental sensitivities. *
I have diabetes. *
(Type II, Adult Onset, NIDDM)
I suffer from Post-Traumatic Distress Syndrome. *
I suffer from anorexia. *
I have oner or more other chronic illnesses or diseases. *
Energy Patterns
I often have to force myself in order to keep going. Everything seems like a chore. *
I am easily fatigued. *
I have difficulty getting up in the morning. *
(I don't really wake up until about 10:00 am)
I suddenly run out of energy. *
I usually feel much better and fully awake after the noon meal. *
(Lunch)
I often have an afternoon low between 3:00pm - 5:00pm. *
I get low energy, moody or foggy if I do not eat regularly. *
I usually feel my best after 6:00pm. *
I am often tired at 9:00pm - 10:00pm but resist going to bed. *
I like to sleep late in the morning. *
My best, most refreshing sleep often comes between 7:00am - 9:00am. *
I often do my best work late at night. *
I often do my best work early in the morning. *
If not in bed by 11:00pm, I get a second burst of energy which often lasts until 1:00am or 2:00am *
Hormone Replacement Survey
Check a box for each symptom which best describes how you have been feeling for the past 4 weeks.
One or more of the following questions may be repeated in another section of this survey. Please answer all questions as each section pertains to different things. Thank you.
Fibrocystic Breast *
Weight Gain *
Heavy or Irregular Menses *
Hot Flashes *
Dry Skin or Dry Hair *
Anxiety *
Depression *
Night Sweats *
Vaginal Dryness *
Headaches *
Irritability *
Mood Swings *
Breast Tenderness *
Sleep Disturbances or Insomnia *
Cramps *
Fluid Retention *
Breakthrough Bleeding *
Fatigue *
Loss of Memory *
Bladder Symptoms *
Arthritis *
Harder to Reach Climax *
Decreased Sex Drive *
Hair Loss *
Detoxification Survey
Please rate each of the following symptoms based on your typical health profile for the past 4 weeks.
HEAD
Headaches *
Faintness *
Dizziness *
Insomnia *
EYES
Watery or itchy eyes *
Swollen, reddened or sticky eyelids *
Bags or dark circles under eyes *
Blurred or tunnel vision *
EARS
Itchy ears *
Earaches, ear infections *
Drainage from ear *
Ringing in ears, hearing loss *
NOSE
Stuffy Nose *
Sinus problems *
Hay fever *
Sneezing attacks *
Excessive mucus formation *
MOUTH / THROAT
Chronic coughing *
Gagging, frequent need to clear throat *
Sore throat, hoarseness, loss of voice *
Swollen or discolored tongue, gums, lips *
Canker sores *
SKIN
Acne *
Hives, rashes, dry skin *
Hair loss *
Flushing, hot flashes *
Excessive sweating *
HEART
Chest pain *
Irregular or skipped heartbeat *
Rapid or pounding heartbeat *
LUNGS
Chest congestion *
Asthma, bronchitis *
Shortness of breath *
Difficulty breathing *
DIGESTIVE TRACT
Nausea, vomitting *
Diarrhea *
Constipation *
Bloated feeling *
Belching, passing gas *
Heartburn *
Intestinal/stomach pain *
JOINTS / MUSCLE
Pain or ahces in joints *
Arthritis *
Stiffness or limitation of movement *
Feeling of weakness or tiredness *
Pain or aches in muscles *
WEIGHT
Binge eating/drinking *
Craving certain foods *
Excessive weight *
Water retention *
Underweight *
Compulsive eating *
ENERGY / ACTIVITY
Fatigue, sluggishness *
Apathy, lethargy *
Hyperactivity *
Restlessness *
MIND
Poor memory *
Confussion, poor comprehension *
Difficulty in making decisions *
Stuttering or stammering *
Slurred speach *
Learning disability *
Poor concentration *
Poor physical coordination *
EMOTIONS
Mood swings *
Anxiety, fear, nervousness *
Anger, irritability, aggressiveness *
Depression *
OTHER
Frequent illness *
Frequent or urgent urination *
Genital itch or discharge *
Stress survey
Please read each of the following statements and select the answer that best describes your feelings or reactions throughout the course of the day.
Some questions may appear redundant between sections. There is a reason for each question. Don't spend much time on any one question.
Section A
when under stress for two weeks or longer I...
Get wound up when I get tired and have trouble calming down. *
Feel driven, appear energetic but feel "burned out" and exhausted. *
Feel restless, agitated, anxious, and uneasy. *