Please enable JavaScript in your browser to complete this form.Name *FirstLastContact Number *Email *Hot flashes, sweating? *NoneNoneMildModerateSevereExtremely Severe(episodes of sweating) Heart discomfort *NoneNoneMildModerateSevereExtremely Severe(unusual awareness of heart beat, heart skipping, heart racing, tightness) Sleep problems *NoneNoneMildModerateSevereExtremely Severe(difficulty in falling asleep, difficulty in sleeping through the night, waking up early) Depressive mood *NoneNoneMildModerateSevereExtremely Severe(feeling down, sad, on the verge of tears, lack of drive, mood swings)Irritability *NoneNoneMildModerateSevereExtremely Severe(feeling nervous, inner tension, feeling aggressive)Anxiety *NoneNoneMildModerateSevereExtremely Severe(feeling panicky)Physical and mental exhaustion *NoneNoneMildModerateSevereExtremely Severe(general decrease in performance, impaired memory, decrease in concentration, forgetfulness)Sexual problems *NoneNoneMildModerateSevereExtremely Severe(change in sexual desire, n sexual activity and satisfaction)Bladder problems? *NoneNoneMildModerateSevereExtremely Severe(difficulty in urinating, increased need to urinate, bladder incontinence)Dryness of vagina *NoneNoneMildModerateSevereExtremely Severe(sensation of dryness or burning in the vagina, difficulty with sexual intercourse)Joint and muscular discomfort *NoneNoneMildModerateSevereExtremely Severe(pain in the joints, rheumatoid complaints)Do you have cold hands and feet? *YesYesNoDo you have daily bowel movements? *YesYesNoDo you have gas, bloating or abdominal pain after eating? *YesYesNoPlease select your WEEKLY Activity Level based on this criteria *0-1 day per week (Low) 0-1 day per week (Low) 2-3 days per week (Average)More than 3 days per week (High)Physical activity that accelerates heart rate / BreathlessnessPlease share any additional comments about your symptoms you would like to address.Please list any prior hormone therapy?Fee Acknowledgement *YesAlthough more insurance companies are reimbursing patients for Bio-Identical Hormone Replacement Therapy, there is no guarantee. You will be responsible for payment in full at the time of your BHRT procedure (see fee schedule below). New Patient Consultation Fee (free for members) $150. Female Hormone Pellet Insertion Fee $350 Chart IDOffice Use OnlyDOBOffice Use OnlyAPP Date?Office Use OnlySubmit & Book Appointment