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
Our Team
- Our Locations
- Blog
Hormones
Treatment & Pricing
- Patient Testimonials
- Recommended Reading
Contact
FREE 15-Min Consultation

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

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