Hormone Balancing Questionnaire

Female-Hormone Balancing Questionnaire

PERSONAL INFORMATION

FULL NAME *

Email *

DOB *

HOW DID YOU HEAR ABOUT US? *

Weight (lbs) *

WHAT DO YOU EXPECT FROM BHRT? *

TELEPHONE *

ADDRESS *

Height (cms) *

BMI *

DATE OF YOUR LAST MENSTRUATION [Menopause ONLY] *

Address Details *

Flat/House No./ Building/Apartment Name

Street Address

City State/Region/Province

Postal / Zip Code Country

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 *

Night sweats *

Mood swings *

Depression *

Poor memory *

Vaginal dryness *

Hot flushes *

Weight gain *

Irritability *

Tiredness *

Loss of interest in sex/ loss of libido *

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 *

DO YOU TAKE ANY SUBSTANCES I.E. HARD DRUGS? *

HOW MUCH ALCOHOL INTAKE I.E. UNITS WEEKLY? *

SPORTS: TYPES / HOW OFTEN

OTHER COMMENTS *

To help our medical team gain a complete understanding of your health profile, please complete the Menopause Symptom Questionnaire and upload any relevant medical history, laboratory results, imaging reports, or additional health information you would like us to review.

Upload

I have read and agree to the Terms & Conditions, Privacy Policy, and Refund & Cancellation Policy. I confirm that the information provided is accurate and complete to the best of my knowledge. *

Female-Hormone Balancing Questionnaire

Female-Hormone Balancing Questionnaire

Lifestyle & Eating Habits

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Female-Hormone Balancing Questionnaire

Female-Hormone Balancing Questionnaire

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