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. Please enable JavaScript in your browser to complete this form.Title *MissMrsMsMrSirDrProfOtherName *FirstLastEmail Address: *Contact Number: *Date of Birth: *Postcode: *SYMPTOMS (Please check each symptom/condition below that applies to you:) *Hot FlushesNight SweatsHeart PalpitationsDry SkinWrinkled SkinUrinary IncontinenceVaginal DrynessErection DifficultiesLow LibidoForgetfulness/Brain FogPoor MemoryLow EnergyInsomniaBreast TendernessFluid RetentionPMSBloatingDepressionAnaemiaSleeping DifficultyAnxietyLow Self EsteemMood SwingsAnger/IrritabilityJoint PainIrregular PeriodsHair Thinning/LossLoss of Muscle ToneWeight GainAdditional Comments and/or SymptomsHave you received any hormone treatment? *On BHRT/HRTStopped BHRT/HRT LESS than 6 months agoStopped BHRT/HRT OVER 6 months agoNever been on any BHRT/HRT treatmentProducts/supplements sourced online/in-store (capsules e.g.)Marketing Preference *PhoneEmailTextNo marketing, thank youWe DO NOT pass details on to anyone else.How did you first hear out about Dr Whitelaw/Equilibrium? *GoogleFacebookTwitterInstagramLeaflet/BrochureLocal TalkRadioMagazine/NewspaperRecommendationLocal SalonOtherAgent Referral (if applicable)Please let us know the name of the person or business who told you about us (e.g salon, nutritionist etc.)WebsiteSubmit Questionnaire