Bio-Identical Questionnaire
Please answer all of the questions as accurately and as fully as possible.

Please complete your questionnaire at least two (2) days before your scheduled appointment.
Email address *
Hormonal Harmony follows all HIPAA guidelines in the collection of Protected Health Information (PHI).
1. Patient Information
First Name *
Last Name *
Date of Birth *
Age *
Are you covered by Medicare? *
2. How did you hear about us? *
3. Name of the person who referred you?
4. What are the top three symptoms/problems related to hormones you would like to see improved, in the order of most important to least important? *
5. Please score the factors below on a scale of 1 to 10 (1 = Awful, 10 = Outstanding)
Your energy level
Your sense of well-being
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