The Hormone Center

Bio-Identical Questionnaire

Hello! Thank you for taking the first step in helping us to evaluate the best options for you.

Please be sure to click "OK" at the end of each page in order to save your answers.

Also, please answer all of these questions as accurately and as fully as possible - you will not be able to go in and edit your responses after you submit.

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Please complete your questionnaire and all consent forms at least two (2) days before your scheduled appointment.

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* 1. Patient Information

First Name

Last Name

Date of Birth

Age

Address

City

State

Zip Code

Cell Phone

Alternative Phone

Email Address

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* 2. How did you hear about us:

Compound Pharmacy

Current Patient

Event/Seminar

Internet/Website

Doctor

Hormone Center Employee

Live/Work in Area

Other

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* 3. Can you tell us more about who referred you?

Name of person who referred you

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* 4. What are the top three symptoms/problems related to hormones you would like to see improved, in order of most important to least important?

Reason #1

Reason #2

Reason #3

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* 5. Please score the factors below on a scale of 1 to 10 (1 = None, 10 = Significant)

	1	2	3	4	5	6	7	8	9	10
My energy level	My energy level 1	My energy level 2	My energy level 3	My energy level 4	My energy level 5	My energy level 6	My energy level 7	My energy level 8	My energy level 9	My energy level 10
My sense of well-being	My sense of well-being 1	My sense of well-being 2	My sense of well-being 3	My sense of well-being 4	My sense of well-being 5	My sense of well-being 6	My sense of well-being 7	My sense of well-being 8	My sense of well-being 9	My sense of well-being 10