TELEPHONE

ADDRESS

DOB

NATIONALITY

NUMBER OF CHILDREN

HOW DID YOU HEAR ABOUT US? 

WEIGHT/ HEIGHT/ BMI

WHAT DO YOU EXPECT FROM BHRT?

DATE OF YOUR LAST MENSTRUATION [if in Menopause]

 YOUR MENSTRUAL CYCLE: DURATION OF BLEEDS, FREQUENCY BETWEEN BLEEDING, ANY CHANGES? [Perimenopause ONLY]

WHAT CURRENT CONTRACEPTION ARE YOU ON? If none, please state none

ANY MEDICAL CONDITIONS IN THE PAST: MIGRAINE, CLOTS IN THE BLOOD, CARDIO PROBLEM INCLUDING HIGH BLOOD PRESSURE, HIGH CHOLESTROL OR DIABETES?

DO YOU HAVE ANY FIRST DEGREE FAMILY HISTORY OF BREAST CANCER?

ARE YOU CURRENTLY ON ANY MEDICATION/ SUPPLEMENTS? Please specify

ARE YOU VEGETARIAN/ VEGAN? 

DO YOU SMOKE? If so, how often, how many cigarettes of grams of tobacco if rolls

WHAT ARE YOUR SLEEPING HABITS? Please describe

HOW MUCH ALCOHOL INTAKE i.e. units weekly?

DO YOU TAKE ANY SUBSTANCES ie. hard drugs?

SPORTS: types/ how often?

OTHER COMMENTS:

PLEASE NOTE THAT IT IS VITAL FOR US TO RECEIVE YOUR COMPLETED MENOPAUSE SYMPTOM QUESTIONNAIRE WITH ANY ADDITIONAL MEDICAL HISTORY INFORMATION/EXAMINATION/RESULTS YOU MAY WISH TO PROVIDE OUR MEDICAL TEAM.

TERMS & CONDITIONS / BHRT / PEPTIDE THERAPY CONSENT