Name: Women's Menopause & Hormone Consultation Questionnaire - Town & Country Compounding
Published: 2021-04-09T21:34:42+00:00

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Age*
Phone (Home)*
Cell
Email
Best Time to contact

: Hours

Minutes
Occupation
Employment*
- Part Time
- Full Time
- Retired
- Unemployed
Living Situation
- Spouse
- Alone
- Partner
- Friend(s)
- Parent(s)
- Children
Height
Weight
Waist Size
BMI
Have you had a hysterectomy?*
- Yes
- No
If yes, When?*
Do your ovaries remain?*
- Yes
- No
How did you arrive at the decision to consider Bio-identical Hormone Replacement Therapy?*
Referred by:*
- Doctor
- Friend/Family Member
- Self
Doctor Name
What are your goals with taking BHRT?*
What is your level of stress?*
- Low
- Moderate
- High

Question Documentation Form

Please write down any questions you may have about Prescription Bio-Identical Hormone Replacement Therapy (Rx BHRT), other medications, or any other questions that come up as you read through the materials you have received. Bring this question sheet with you to your consultation so you can discuss this information with your pharmacist. Thank you.
1
2
3
4
5
6

COMMUNICATION CONSENT FORM
Signature
Max. file size: 50 MB.
Date
MM slash DD slash YYYY
Name
First Last
Please list any persons to whom we are permitted to give information to (give name and relationship).
Name and Relationship

Women’s Menopause & Hormone Consultation Questionnaire

DO YOU HAVE A QUESTION FOR A PHARMACIST?