Please enable JavaScript in your browser to complete this form.Full NameFirstLastEmail AddressPhone NumberDate of BirthAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMedical History – Check all that applyHot flashesNight sweatsMood changesLow libidoVaginal drynessFatigueWeight gainBrain fogDepression or anxietyErectile dysfunctionIrregular or missed periodsSleep disturbancesHair thinningRelevant Medical HistoryCurrent MedicationsKnown AllergiesDo you currently use:Tobacco?Alcohol?Recreational drugs?Have you been diagnosed with or experiencing the following?Breast cancerOvarian or uterine cancerProstate cancerHeart disease or heart attackStroke or TIABlood clots or DVT/PEHigh blood pressureLiver diseaseOsteoporosis or bone lossHave you had a hysterectomy?YesNoHave you had an oophorectomy (ovary removal)?YesNoDo you exercise regularly?YesNo are Known apply Are you currently pregnant or breastfeeding?YesNoN/ADate of last period (if applicable)Are your cycles regular? YesNoN/ADo you experience pain or discomfort during sex?YesNoN/AWhat are your goals for hormone therapy? (Check all that apply)Symptom reliefImprove mood and energyPrevent osteoporosisImprove sexual functionOtherConsent and AcknowledgementI acknowledge that the information provided above is accurate to the best of my knowledge.I understand that lab testing are needed to assess hormone levels and overall health.I understand that hormone therapy has risks and requires regular monitoring.Date / TimeDateTimeSubmit
