Medical Questionnaire

Medical Questionnaire
Full Name*

First NameLast Name
E-mail Address*
example@example.com
Contact Number*
Mailing Address*

Street Address

Street Address Line 2

CityState

Post Code
We are only licensed to ship prescriptions to Utah right now - but we're expanding quickly! If you are from a different state and interested, fill out this form and we'll let you know when we are able to ship to you.
Sex at Birth*

FemaleMale
Date of Birth*

DayMonthYear
Check all that apply in the last 3-6 months:

Trouble falling asleep or staying sleepMood swings, anxiety, or irritabilityBreast tenderness or swellingDecreased libidoHeadaches tied to cycleNight sweats or hot flashesIrregular or heavy menstrual bleedingWeight gain or bloatingFatigue or brain fog
Are you currently:*

Still having regular periodsHaving irregular periodsNo periods for 12+ monthsOn birth control (pill, patch, ring IUD)
Have you ever been diagnosed with?*

PCOSPerimenopauseMenopauseNone of the above
Are you currently taking any hormone therapy (estrogen, testosterone, DHEA, progesterone)?*

NoIf yes, list dose and form:
Are you currently pregnant or breastfeeding?*

YesNo
Have you had a hysterectomy or ovary removal?*

YesNo
Have you ever had any of the following:

History of unexplained vaginal bleedingHistory of breast cancer or other hormone sensitive cancerHistory of blood clots, DVT, or pulmonary embolismHistory of liver disease, hepatitis, or abnormal liver functionDepression or severe mood disordersHeart attack or heart disease
If you marked any of the above, please provide details (diagnosis, year, current status, treatments, etc).
What medications are you currently taking (prescriptions, OTC, supplements)?
Do you have any allergies?
Allergen and symptoms
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

YesNo
Please provide details.
Have you had recent hormone labs?*

NoIf yes, please list results:
Consent

I understand the risks and benefits of progesterone therapy have been explained to me.

I consent to share this information with the prescribing provider and compounding pharmacy.
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What is your primary goal with hormone therapy?

Improve sleepReduce night sweats or hot flashesStabilize moodRegulate cyclesOther
How did you hear about us?*

InstagramAdvertisementReferral:

My Products*

Progesterone Package- Complete symptom and health history review, personalized progesterone therapy plan, first month prescription, home delivery, and patient support from our team.

$199.00 Quantity

Total

$0.00

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