Menopause health and lifestyle survey

Complete this survey before your scheduled free menopause phone consultation.

Hormone consultation patient evaluation form
Please tell us your full name
DD/MM/YYYY
Lifestyle history *
Please select all that apply
Please tell us if you have any known allergies to foods, medications, or specific environments, along with a brief description of any allergic reactions you've experienced.
Please list all non-prescription medications that you are taking. Include vitamins, herbals, and supplements.
Please list any conditions or diseases that you have been diagnosed with or suffer from. (For example: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc).
Please list any medications you're currently taking (including hormones). If you've taken a hormone treatment in the past, please include that information here as well.
Have you ever used oral contraceptives (birth control)? *
Have you had any of the following? *
Have you had any of the following preventative screening procedures? *
If yes, please list any family members with this/these conditions.
Please tell us: The age you first had your period; whether your menstrual flow was heavy or light; how many days your cycle lasted; whether you experienced clotting; whether you think you experienced any abnormal cycles.
Please describe any symptoms you experienced.
Have you experienced any of the following?
Please select any that apply