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Home
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IV Therapy
Opioid Free
Store
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Resources
Blog
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For Patients
Provider Portal
Locations
Southlake
Garland
SCHEDULE APPOINTMENT
Healing Comfortably Into The Future
feMale Hormone
Intake Questionnaire
Click Here to complete questionnaire
Female Hormone Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Select
Male
Female
Coupon Code
In your own words tell us what your complaint is
*
example: "I am tired all the time", or "My left knee hurts"
Email
*
Mobile Phone
*
(###)
###
####
How may we contact you?
*
Cell Phone
Text
E-Mail
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
(###)
###
####
Primary Care Physician
First Name
Last Name
Primary Care Physician Phone
(###)
###
####
Height (Feet)
*
Select
1
2
3
4
5
6
Height (Inches)
*
Select
1
2
3
4
5
6
7
8
9
10
11
Weight
*
In pounds
Have you ever had problems with Anesthesia?
*
Has anesthesia ever caused severe Fever, Cardiac Arrest, Dark Colored Urine, or admission to the ICU
Select
Yes
No
Do you Smoke?
*
Select
Yes
No
Do you drink Alcohol?
*
Select
Yes
No
Do you have any allergies to medication?
*
Select
Yes
No
If yes, please list below
Please list all medications below
Please list all vitamins and supplements below
Please list all past surgeries below
Family History
*
Have any of your parents, grandparents, or siblings experienced any of the following?
None
Heart Disease
Diabetes
Cancer
Severe Depression
Alzheimer's or Dementia
Other
Personal Medical History
*
High blood pressure
Heart bypass
High cholesterol
Heart Disease (other)
Heart attack
Angina or other chest pain
Stroke or TIA
Blood clot and/or a pulmonary emboli
Arrhythmia
Pacemaker
Defibrillator
Anemia
Asthma
Emphysema
COPD
Hepatitis
HIV/AIDS
Lupus or other auto immune disease
Fibromyalgia
Trouble passing urine or take Flomax or Avodart
Chronic liver disease (fatty liver or cirrhosis)
Diabetes (Type 1)
Diabetes (Type 2)
Thyroid disease
Arthritis
Depression
Anxiety
ADD/ADHD
Cancer
Other
NONE
Birth Control Method
*
Applies to Females only
Menopause
Hysterectomy
Tubal Ligation
Birth Control Pills
Vasectomy
Other
None
Preventative care
*
List all that apply
Medical/GYN Exam in the last year
Mammogram in the last 12 months
Bone Density in the last 12 months
Pelvic ultrasound in the last 12 months
None
Are you currently receiving Hormone Replacement Therapy?
*
Yes
No
Hormone Assessment
*
Do you experience any of the following? (Check all that apply)
Hot flashes
Sweating
Heart discomfort
Sleep problems
Depressive mood
Irritability
Anxiety
Physical exhaustion
Sexual problems
Bladder problems
Dryness of vagina
Joint Discomfort
Muscular Discomfort
Mental exhaustion
Brain Fog
Cold (hands and feet, or temperature intolerance)
Constipation
Dry skin or hair
Brittle hair or nails
Hair loss
Weight gain
Inability to lose weight
How long have you been experiencing these symptoms?
*
Overall how would you rate your symptoms? *
*
Mild
Moderate
Severe
Are you currently experiencing pain?
*
Yes
No
Current Pain
*
Select where you are currently experiencing pain or choose "not currently experiencing pain"
Select
Not currently experiencing pain
Head
Face
Neck
Back
Shoulder
Elbow
Forearm
Wrist
Hand
Hip
Knee
Ankle
Foot
Abdomen
On a scale of 1-10 please rate your pain
1
2
3
4
5
6
7
8
9
10
How Did You Hear About Us???
*
Select
Personal Referral (enter name in next question)
Office Sign
Website
Facebook
Instagram
Youtube
Pinterest
Twitter
Other Social Media
IFM Website
Other (enter in next question)
Enter name of person referring you or other
Please Send Any Additional Medical Records, Labs, X-Rays, CT Scans, or MRI's to KAAPS@KRYSTALANESTHESIA.COM
Thank you for completing you questionnaire
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