Pre Consultation Questionnaire - Equilibrium Clinic - Hormone Treatment for Menopause and other hormone related conditions

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An holistic approach to restoring and maintaining hormone balance

Home
About
Hormones
- Recommended Reading
Services
Contact
FREE 15-Min Consultation
News
COVID-19
- Customised4U Pharmacy

Pre Consultation Questionnaire

Pre-Consultation Questionnaire

You need only complete this form if you have an appointment with us and have been asked to do so.

Title *

Miss
Mrs
Ms
Mr
Sir
Dr
Prof
Other

Name *

First

Last

Email Address: *

Contact Number: *

Date of Birth: *

Postcode: *

SYMPTOMS (Please check each symptom/condition below that applies to you:) *

Hot Flushes
Night Sweats
Heart Palpitations
Dry Skin
Wrinkled Skin
Urinary Incontinence
Vaginal Dryness
Erection Difficulties
Low Libido
Forgetfulness/Brain Fog
Poor Memory
Low Energy
Insomnia
Breast Tenderness
Fluid Retention
PMS
Bloating
Depression
Anaemia
Sleeping Difficulty
Anxiety
Low Self Esteem
Mood Swings
Anger/Irritability
Joint Pain
Irregular Periods
Hair Thinning/Loss
Loss of Muscle Tone
Weight Gain

Additional Comments and/or Symptoms

Have you received any hormone treatment? *

On BHRT/HRT
Stopped BHRT/HRT LESS than 6 months ago
Stopped BHRT/HRT OVER 6 months ago
Never been on any BHRT/HRT treatment
Products/supplements sourced online/in-store (capsules e.g.)

Marketing Preference *

Phone
Email
Text
No marketing, thank you

We DO NOT pass details on to anyone else.

How did you first hear out about Equilibrium Clinic? *

Agent Referral (if applicable)

Please let us know the name of the person or business who told you about us (e.g salon, nutritionist etc.)

Comment

Copyright 2020. All rights reserved. Hormone Health Clinic Ltd, trading as Equilibrium is a company registered in England and Wales (Reg. No. 10426680).

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