Womens Health Consultation Form

This form is designed to help you describe your symptoms to us as quickly and easily as possible. If you are not sure if you should be filling this form out, or if you have any questions, please contact us at 1-800-991-9079 and Press 1.

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Please fill out the consultation form below to be contacted by one of our specialists. All information is secure and private! Once you've filled out all fields, please click the "Submit Form" button at the bottom to proceed.

Fields marked with an asterisk (*) are required!

Your Information
First Name:*
Middle Initial:
Last Name:* Nick Name:
Date of Birth:*
Home Phone:*
Cell Phone:
Work Phone:

Insurance / Doctor Information
Insurance Company:

Prescription Benefit
Card Number:
Prescription Group Number:

Prescription Help Desk Phone Number:
Physician First Name:
Physician Last Name:
Physician Address:
Physician City:
Physician State:
Physician Zip:
Physician Phone:
How did you hear about us?
Person's Name / Description:

Medical History
Please list the current prescription drugs you are taking:
Please list the current vitamins or herbals you are taking:
Do you have any allergies?:*
If yes, what food or medications?:
Do you smoke?:*

If so, how many
cigarettes per day? 
How many caffeinated drinks do you drink a day?:* How many carbonated drinks do you drink a day?:*
Do you exercise?:*

If so, what type?:
How many times per week?: 
Have you had a hysterectomy?:*

If so, when?:
Was it full or partial?:
What was the reason for your Hysterectomy?:
Are you still menstruating?:*

Last date of menstruation?:
Please list any changes in your menstruation: (i.e. heavier, longer, shorter, etc.)
Have you given birth?:
If so, how many times?
Have you had a miscarriage?:
If so, how many times?  
Have you had Tubal Ligation?:*

If so, when?:
Have you been diagnosed or take medication for the following medical conditions?
High Blood Pressure?:*

Ovarian Cysts?:*

Fibrocystic Breast Lumps?:*

Blood Clots?:*



Low Thyroid?:*

Elevated Thyroid?:*

High Cholesterol?:*

Uterine Fibroids?:*



What other Medical Conditions do you have?:
Do you have any family history of osteoporosis?:
Have you taken hormones,
including birth control?:*

If so, which ones and how long did you take them?:
Have any women in your family
had breast, uterine, ovarian,
or cervical cancers?:*

If so, please list each with relation:
Have you had an
abnormal Mammogram?:*

If so, please list any details:
Have you had an
abnormal Pap Smear?:*

If so, please list any details:
Any other information that you feel may be helpful for us?:
Please fill in any of the following symptoms that you may be experiencing?
Please fill in each entry below with a number between 0 through 10.
0 being nothing, 1 through 3 being Mild, 4 through 7 being Moderate, 8 through 10 being Severe.
If you have none of these symptoms please leave at 0.
Hot Flashes:

Night Sweats:

Vaginal Dryness:

Memory Loss:

Yeast Infections:

Bladder Infections:

Difficulty Concentrating:

Painful Joints:

Urinary Incontinence:


Mood Swings:

Breast Tenderness:





Water Retention:

Dry Skin:

Dry Hair:

Hair Loss:

Loss of Sex Drive:



Muscle Weakness:

Weight Gain:

Please click the "Submit Form" button to proceed.

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