Menopause Questionnaire for New Patients

Bioidentical Testosterone and Estradiol Pellets for the Treatment of Menopause:

Is BioBalance bioidentical hormone pellet therapy right for you?

Are you a candidate for BioBalance bioidentical testosterone or estradiol pellet therapy? Fill out our self-evaluation and we’ll let you know if BioBalance Health can help you “get your life back!”

We will email our recommendations to you!

First Name:
Last Name:
Email:
Phone Number:
Birthdate:
Symptoms
I have severe hot flashes and night sweats
My sleep is difficult and not restful
I have recent changes in my mood-new anxiety and /or depression
I have PMS
My sex drive is gone
I can no longer achieve orgasm
My husband/ partner and I are no longer getting along
I am more irritable than I was a few years ago
I have a new onset of migraine headaches after age 35
I don’t feel like myself anymore
I have recently developed dry eye
I have recently gained weight in my abdomen
My skin droops and has lost its elasticity
My energy is nonexistent
I feel hopeless
I can’t remember names of things and feel mentally foggy
My strength and exercise tolerance is diminished
I no longer enjoy life
I am no longer motivated to get out of bed
My joints ache and I have a new onset of arthritic symptoms

Medical Status
I have completed child-bearing
I am using birth-control or am menopausal or have had a hysterectomy
I have seen a Gynecologist in the last year for preventive care

Medical Factors Affecting Possible Treatment
I have fibroids of the uterus
I have had breast cancer or endometrial uterine cancer
I have chronic liver disease (e.g., Hepatitis, fatty liver, cirrhosis)
I have Diabetes
I have had a stroke and/or a heart attack
I have had a blood clot and/or a pulmonary emboli
I smoke
I drink more than 7 drinks of alcohol per week
My BMI is greater than 35

If you were referred by a physician, please enter his/her name here:
If you were not referred by a physician, how did you hear about BioBalance Health?
By completing this questionnaire and submitting it to BioBalance Health, you have indicated that you understand that this evaluation is only a screening tool to see if you are a candidate for BioBalance Health bioidentcial hormone replacement therapy. A face-to-face consultation in our office is necessary to complete your full evaluation.

Check here if you would like to receive new updates in treatment and therapy options.