Female Lifestyle Questionnaire

New Patient Contact

Mailing Address

Background Information

Date of Birth

Occupational Profile

Your Household

Please select...

Your BHRT Goals

Please describe your expectations and goals as a patient at RejuvinAge.

Medical History

Cancer diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Diabetes diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Heart disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Arthritis diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Liver disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

High cholesterol / triglycerides diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Endocrine / thyroid abnormalities?

Myself

Sibling

Parent

N/A

Please Select...

High blood pressure?

Myself

Sibling

Parent

N/A

Please Select...

Bowel disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Neurological disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Lung disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Kidney disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Medical History Cont'd

Stomach disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Blood clots?

Myself

Sibling

Parent

N/A

Please Select...

Weight control problems?

Myself

Sibling

Parent

N/A

Please Select...

Osteoporosis / Osteopenia diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Anemia diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Alcohol abuse?

Myself

Sibling

Parent

N/A

Please Select...

Drug abuse?

Myself

Sibling

Parent

N/A

Please Select...

Have you had any surgical procedures?

Yes

No

Please select...

Past serious injury or illness?

Yes

No

Please select...

Tests & Examinations

When was your last menstrual period?

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When was your last Pap smear?

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When was your last breast exam?

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When was your last mammogram?

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Have you had a colonoscopy?

Yes

No

Please select...

When was your last Colonoscopy?

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Have you had a rectal exam?

Yes

No

Please select...

When was your last rectal exam?

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Have you had a bone density test?

Yes

No

Please select...

When was your last bone density test?

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Have you had a chest x-ray?

Yes

No

Please select...

When was your last chest x-ray?

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Have you had an EKG?

Yes

No

Please select...

When was your last EKG?

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Medications & Supplements

Do you have any medication allergies?

Yes

No

Please select...

Are you currently taking any medication(s)?

Yes

No

Please select...

Are you currently taking any supplements?

Yes

No

Please explain...

Health & Lifestyle

What is your daily water consumption?

Please select...

What is your daily caffeine consumption?

Please select...

Are you a tobacco user?

Currently use

Previously used

Never used

Please select...

Do you consume alcohol?

Currently use

Previously used

Never used

Please select...

Do you take recreational drugs?

Currently use

Previously used

Never used

Please select...

Health Survey

Do you experience fatigue?

Yes

No

Please select...

Do you have any skin disorders?

Yes

No

Please select...

Do you experience visual problems?

Yes

No

Please select...

Hearing loss or ringing in ears?

Yes

No

Please select...

Do you experience allergy symptoms?

Yes

No

Please select...

Do you experience headaches?

Yes

No

Please select...

Do you have spider or varicose veins?

Yes

No

Please select...

Lumps in neck, armpits, or groin?

Yes

No

Please select...

Do you have breast lumps?

Yes

No

Please select...

Do you have shortness of breath?

Yes

No

Please select...

Do you experience heart palpitations?

Yes

No

Please select...

Health Survey Cont'd

Do you experience abdominal pain?

Yes

No

Please select...

Do you experience regular diarrhea?

Yes

No

Please select...

Do you experience regular constipation?

Yes

No

Please select...

Do you urinate thru at night?

Yes

No

Please select...

Do you have a sexually transmitted disease?

Yes

No

Please select...

Fluid retention in hands, legs, or ankles?

Yes

No

Please select...

Do you have abdominal bloating?

Yes

No

Please select...

Do you suffer from indigestion?

Yes

No

Please select...

Do you have acid reflux?

Yes

No

Please select...

Health Survey Cont'd

Do you have any food allergies?

Yes

No

Please select...

Do you have any food sensitivities?

Yes

No

Please select...

Do you have oily skin?

Yes

No

Please select...

Do you have a history of adult acne?

Yes

No

Please select...

Do you have excessive body hair?

Yes

No

Please select...

Do you suffer from joint pain?

Yes

No

Please select...

Do you suffer from back or spine pain?

Yes

No

Please select...

Do you have difficulty losing weight?

Yes

No

Please select...

Do you have a lack of mental alertness?

Yes

No

Please select...

Do you suffer from poor memory?

Yes

No

Please select...

Health Survey Cont'd

Do you suffer from poor concentration?

Yes

No

Please select...

Have you noticed a decrease in energy?

Yes

No

Please select...

Do you suffer from sleep problems?

Yes

No

Please select...

Do you have a decreased self-image?

Yes

No

Please select...

Do you experience rapid mood swings?

Yes

No

Please select...

Do you have dry or brittle nails?

Yes

No

Please select...

Do you have dry hair?

Yes

No

Please select...

Is your hair thinning or falling out?

Yes

No

Please select...

Do you have cold hands or feet?

Yes

No

Please select...

Female Hormone Quiz

Do you suffer from disruptive hot flashes?

Yes

No

Please select...

Are you experiencing uncharacteristic mood changes?

Yes

No

Please select...

Do you have breast tenderness or sensitivity?

Yes

No

Please select...

Do you have vaginal dryness?

Yes

No

Please select...

Are you sexually active?

Yes

No

Please select...

Is sexual intercourse painful?

Yes

No

Please select...

Has enjoyment from sex decreased?

Yes

No

Please select...

Has your desire for sex decreased?

Yes

No

Please select...

Is sexual arousal diminished?

Yes

No

Please select...

Have your periods become irregular?

Yes

No

Please select...

Do you experience premenstrual tension or moods?

Yes

No

Please select...

Have you used hormone replacement?

Yes

No

Please select...

What form of birth control do you utilize?

Please select...

Do you experience problems with birth control pills?

Yes

No

Please select...

Bioidentical Hormone Replacement Therapy

Before today, how long have you been considering or researching BHRT?

Under 30 days

2-5 months

6-12 months

Over 12 months

Please select

How did you first learn about RejuvinAge?

Physician Referral

Friend or Family Referral

Online Search Engine

Social Media

Print Advertisement

Please select...

I understand program appointments require in-person visits to our Virginia Beach clinic however initial consultations may be conducted remotely upon request.

I agree to RejuvinAge's patient appointment and refund policies.

You must agree to terms to proceed.

Female Questionnaire

New Patient Contact

Mailing Address

Background Information

Your Household

Your BHRT Goals

Medical History

Medical History Cont'd

Tests & Examinations

Medications & Supplements

Health & Lifestyle

Health Survey

Health Survey Cont'd

Health Survey Cont'd

Health Survey Cont'd

Female Hormone Quiz

Bioidentical Hormone Replacement Therapy

For Women

For Men

BHRT Resources

Privacy & Use

Female Questionnaire

New Patient Contact

Mailing Address

Background Information

Your Household

Your BHRT Goals

Medical History

Medical History Cont'd

Tests & Examinations

Medications & Supplements

Health & Lifestyle

Health Survey

Health Survey Cont'd

Health Survey Cont'd

Health Survey Cont'd

Female Hormone Quiz

Bioidentical Hormone Replacement Therapy

For Women

For Men

BHRT Resources

Privacy & Use

Keep Connected