PCAB Accredited Compounding Pharmacy CQI Partner

Hormone Replacement Therapy Symptom Survey

Please check all symptoms below

Hysterectomy
Yes, Full Yes, Partial No
Absent Mild Moderate Severe
Fibrocystic Breast
Weight Gain
Heavy/Irregular Menses
Hot Flashes
Dry Skin/Hair
Anxiety
Depression
Night Sweats
Vaginal Dryness
Headaches
Irritability
Mood Swings
Breast Tenderness
Sleep Disturbances/Insomnia
Cramps
Fluid Retention
Breakthrough Bleeding
Fatigue
Memory Loss
Bladder Symptoms
Arthritis
Harder to Reach Climax
Decreased Sex Drive
Hair Loss

Personal Information:

First Name*
Last Name*
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Address:
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State / Zip:*
Email Address:*
Phone Number:*
Age:*
Height:*
Weight:*
Supplements currently taking:*
Prescriptions currently taking (name and dose):*
Last Menstrual Period (date ended):*
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  • Contact Us:

    Health Dimensions

    Phone: 800-836-2303
    Fax: 248-489-1586

    Farmington Hours:
    Mon, Wed, Fri: 8:30-5:30
    Tues, Thur: 8:30-7:00

    Canton Hours:
    Mon- Thurs, 8:30-5:00,
    Fri: 8:30-4:00

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