Name:
Email:
Phone:
Date of Birth:

How did you find our site?

1.) Are you currently taking hormones? Detail.


2.) Are you Premenopausal?
Yes No
If yes, what is your average length of cycles, i.e. 26, 27, 28 days?

3.) Are you Perimenopausal (irregular cycles)?
Yes No
If yes, when was your last menses?

4.) Are you Postmenopausal?
Yes No
If yes, when was your last menses?

5.) Are you trying to become pregnant?
Yes No
If yes, do you have a fertility problem?
Yes No

6.) List any PMS symptoms.


7.) Migraine headaches? Yes No
If yes, how often?

If migraines occur on a specific day of cycle, what day?

8.) Have you had a partial or total hysterectomy?
Yes No
If yes, detail problems before and after hysterectomy.


10.) Have you had a Functional Adrenal Stress Profile?
Yes No

11.) Considering Natural Hormone Replacement Therapy?
Yes No

12.) What is your purpose for this hormone evaluation?


13.) List history of hormone driven pathologies i.e., breast cancer, endometriosis.


14.) Select any of the following that apply to you:

15.) Difficulty in falling asleep?
Yes No

16.) Does your mind race? Can't turn off thinking?
Yes No

17.) Are you physically unable to relax?
Yes No
Muscles feel tight?
Yes No

18.) Do you recall your dreams?
Yes No
If yes, are they vivid? Yes No

19.) Do you frequently have nightmares?
Yes No

20.) Do you have a family history of osteoporosis, cancer or cardiovascular disease?
Yes No

21.) Please add any additional comments or concerns.