Hormone Consult Intake Form

Name

First Last

Email*

Phone*

Birth Date*

Address*

Street Address Address Line 2 City Province Postal Code

Height*

Weight*

Alberta Health Care Number*

Allergies*

Please list any Medication, Food or Environmental allergies you have and your reactions.

Current Medications*

Vitamins, herbs, dietary or nutritional supplements:

Which hormone service are you interested in?*

Vitality Coaching Program

Hormone Advising

Estrogen

Include dose and frequency:

Progesterone

Include dose and frequency:

Testosterone

Include dose and frequency:

DHEA

Include dose and frequency:

Pregnenolone

Include dose and frequency:

Other

Include dose and frequency:

Have you tried any hormones that have not worked for you?*

Yes

No

If yes, please list:*

How did you hear about us?*

Did you receive a referral for our hormone services?