Pre Consultation Questionnaire Pre-Consultation Questionnaire 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 Equilibrium Clinic? *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.)CommentSubmit Questionnaire
