Hormone Balancing Questionnaire

Personal Information

FULL NAME *

TELEPHONE *

Email *

ADDRESS *

DOB *

CURRENT AGE *

HOW DID YOU HEAR ABOUT US? *

WEIGHT/ HEIGHT/ BMI *

WHAT DO YOU EXPECT FROM BHRT? *

DATE OF YOUR LAST MENSTRUATION [Menopause ONLY] *

YOUR MENSTRUAL CYCLE: DURATION OF BLEEDS, FREQUENCY BETWEEN BLEEDING, ANY CHANGES? [Perimenopause ONLY] *

WHAT CURRENT CONTRACEPTION ARE YOU ON? If none, please state none

ARE YOU ON ANY HORMONE THERAPY RIGHT NOW? If so please specify

ANY MEDICAL CONDITIONS IN THE PAST: MIGRAINE, BLOOD CLOTS , CARDIO INCLUDING HIGH BLOOD PRESSURE, HIGH CHOLESTROL OR DIABETES? *

DO YOU HAVE ANY FIRST DEGREE FAMILY HISTORY OF BREAST CANCER? *

HOW MUCH YOU ARE TROUBLED BY ANY OF THESE SYMPTOMS AT PRESENT? Please specify

Stress *

Hot flushes *

Night sweats *

Weight gain *

Mood swings *

Irritability *

Depression *

Tiredness *

Poor memory *

Loss of interest in sex/ loss of libido *

Vaginal dryness *

Urinary symptoms *

ARE YOU CURRENTLY ON ANY MEDICATION/ SUPPLEMENTS? Please specify *

HAVE YOU HAD ANY HYSTERECTOMY OR ANY OTHER SURGERIES IN THE PAST? Please specify

LIFESTYLE & EATING HABITS

ARE YOU VEGETARIAN/ VEGAN? *

HOW MUCH WATER DO YOU DRINK PER DAY? *

DO YOU SMOKE? If so, how often, how many cigarettes of grams of tobacco if rolls *

WHAT ARE YOUR SLEEPING HABITS? Please describe *

HOW MUCH ALCOHOL INTAKE i.e. units weekly? *

DO YOU TAKE ANY SUBSTANCES ie. hard drugs? *

SPORTS: types/ how often?

OTHER COMMENTS *

PLEASE NOTE THAT IT IS VITAL FOR US TO RECEIVE YOUR COMPLETED QUESTIONNAIRE WITH ANY ADDITIONAL MEDICAL HISTORY INFORMATION/EXAMINATION/RESULTS YOU MAY WISH TO PROVIDE OUR MEDICAL TEAM.

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Female-Hormone Balancing Questionnaire

Personal Information

HOW MUCH YOU ARE TROUBLED BY ANY OF THESE SYMPTOMS AT PRESENT? Please specify

LIFESTYLE & EATING HABITS

Lifestyle & Eating Habits

Locations

Therapy

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Female-Hormone Balancing Questionnaire

Personal Information

HOW MUCH YOU ARE TROUBLED BY ANY OF THESE SYMPTOMS AT PRESENT? Please specify

LIFESTYLE & EATING HABITS

Lifestyle & Eating Habits

Locations

Therapy

About

Resources

Discovery call

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