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Medical Weight Loss
BEFORE & AFTER
BEFORE & AFTER
PATIENT TESTIMONIALS
MEDICAL WEIGHT LOSS
YOUR INITIAL VISIT
WEIGHT LOSS PROGRAM PRICES
GLP-1 MEDICATIONS
Charlotte GLP Options
Semaglutide for Weight Loss Charlotte NC
Tirzepatide for Weight Loss
APPETITE SUPPRESSANTS
LIPOTROPIC INJECTIONS
LEARN2LOSE PRE-PLANNING CHECKLIST
Optimize Hormones
Male Performance
About
OUR TEAM
DR. DAVID CROLAND
WEIGHT LOSS BLOG
REVIEWS
Payment plans
PatientFi – 0% APR Plans
Cherry – Flexible Monthly Plans
Special Offers
Purchase Gift Cards
Contact / Get Started
LOCATIONS
Ballantyne / Charlotte Location
Matthews Location
CONTACT US
CAREERS
GIFT CARDS
request a medical consultation
Request a medical consultation
Toggle Navigation
Home
Medical Weight Loss
BEFORE & AFTER
BEFORE & AFTER
PATIENT TESTIMONIALS
MEDICAL WEIGHT LOSS
YOUR INITIAL VISIT
WEIGHT LOSS PROGRAM PRICES
GLP-1 MEDICATIONS
Charlotte GLP Options
Semaglutide for Weight Loss Charlotte NC
Tirzepatide for Weight Loss
APPETITE SUPPRESSANTS
LIPOTROPIC INJECTIONS
LEARN2LOSE PRE-PLANNING CHECKLIST
Optimize Hormones
Male Performance
About
OUR TEAM
DR. DAVID CROLAND
WEIGHT LOSS BLOG
REVIEWS
Payment plans
PatientFi – 0% APR Plans
Cherry – Flexible Monthly Plans
Special Offers
Purchase Gift Cards
Contact / Get Started
LOCATIONS
Ballantyne / Charlotte Location
Matthews Location
CONTACT US
CAREERS
GIFT CARDS
request a medical consultation
Please complete the appropriate questionnaire from the options below at least 48 hours prior to your next appointment.
Initial HRT – Female
Follow-up HRT – Female
Initial HRT – Male
Follow-up HRT – Male
Female Initial HRT Intake Questionnaire
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
Month
Date
Year
Current Weight
(Required)
Height (feet)
(Required)
Please enter a number from
4
to
6
.
Height (inches)
(Required)
Please enter a number from
0
to
11.5
.
Which location will you be coming to?
(Required)
Ballantyne
Matthews
Current MenstrualStatus and Hormone History
Have you had a period in the past 12 months?
(Required)
Yes
No
Have you had a hysterectomy?
(Required)
No
Yes
Was it a complete hysterectomy, or do you still have ovaries?
(Required)
Complete - no ovaries
Still have ovaries
First day of your last cycle?
MM slash DD slash YYYY
Are your cycles regular?
(Required)
Yes
No
Have you been on any hormones in the past 6 months (injections, gels, creams, patches, pellets, IUD or pills?
(Required)
Yes
No
Do you take any medications of supplements?
(Required)
Yes
No
Current medications and supplements
(Required)
Add
Remove
Please enter name of drug or supplement and dosage. Click the "+" to add more.
Any Known drug or environmental allergies?
(Required)
Yes
No
Please list any allergies
(Required)
Have you ever been diagnosed with breast cancer?
(Required)
No
Yes
Have you ever had a mammogram?
(Required)
No
Yes
Date of you most recent mammogram?
(Required)
Month / Year
Have you ever had any abnormalities noted on mammogram?
(Required)
Yes
No
Please explain, include dates and follow-up procedures
Medical Conditions (Your Personal History Only)
Please select all that apply
Endometriosis
(Required)
No
Yes
Uterine Fibroids
(Required)
No
Yes
Fibrocystic breasts
(Required)
No
Yes
Thyroid disorder
(Required)
No
Yes
Hashimoto’s Thyroiditis
(Required)
No
Yes
Diabetes
(Required)
No
Yes
Heart disease
(Required)
No
Yes
Hypertension
(Required)
No
Yes
Anxiety
(Required)
No
Yes
Depression
(Required)
No
Yes
Psychiatric illness requiring hospitalization
(Required)
No
Yes
Osteoporosis
(Required)
No
Yes
Breast cancer
(Required)
No
Yes
Blood clots
(Required)
No
Yes
Heart attack and/or Stroke
(Required)
No
Yes
PCOS / Ovarian Cysts
(Required)
No
Yes
Additional conditions NOT listed?
(Required)
No
Yes
Explain "YES" answers / Other pertinent medical history
Symptom Checklist
Rank your symptoms on a scale from 0 to 10. (0 = None, 10 = Severe)
Hot flashes / night sweats (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Breast tenderness (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Mood swings / irritability (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Anxiety / depression (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Decreased sex drive / Low libido (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Painful sex (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Difficult to climax sexually (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Vaginal dryness (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Difficulty sleeping (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Brain fog / Memory loss (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Weight gain (especially midsection) (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Hair thinning / hair loss (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Migraines / severe headaches (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Joint pain / stiffness (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Dry skin / brittle nails (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Feel cold often (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Family History
Do you have a family history of Heart Disease?
(Required)
Yes
No
Do you have a family history of Diabetes?
(Required)
Yes
No
Do you have a family history of Thyroid Disease?
(Required)
Yes
No
Do you have a family history of Breast Cancer?
(Required)
Yes
No
Social History
Marital Status?
(Required)
Never married
Married
Divorced
Separated
Do you have biological children?
(Required)
Yes
No
Do you want to have (more) children?
(Required)
Yes
No
Are you sexually active?
(Required)
Yes
No
No, but would like to be
Do you use any nicotine or tobacco products?
(Required)
Yes
No
Do you consume alcohol?
(Required)
Yes
No
How many drink equivalents per week?
(1 drink equivalent = 1 beer, 5 ounces of wine, 1.5 ounces of spirits)
Δ
Female Follow-up HRT Intake Questionnaire
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
Month
Day
Year
Current Weight
(Required)
Please enter a number from
85
to
400
.
Which location will you be coming to?
(Required)
Ballantyne
Matthews
Virtual
Current Menstrual Status and Hormone History
Have you had a period in the past 12 months?
(Required)
Yes
No
First day of your last menstrual cycle?
(Required)
MM slash DD slash YYYY
Have you been on any hormones in the past 6 months (injections, gels, creams, patches, pellets, IUD or pills?
(Required)
Yes
No
Currenly taking prescription medications or supplements?
(Required)
Yes
No
Current medications, hormones, and supplements
(Required)
Add
Remove
Please enter name of drug or supplement and dosage. Click the "+" to add more.
Date of you most recent mammogram?
(Required)
Month / Year
Were there ANY abnormalities noted?
(Required)
Yes
No
Please explain
Medical Conditions (Your Personal History)
Please list any updates to your medical history since your last consultation
Since your last BHRT consultation, in general, how would you describe how you feel?
(Required)
Much better
Better
About the same
Worse
Much worse
Please describe any changes since last visit
Symptom Checklist
Rank your current symptoms on a scale from 0 to 10. (0 = None, 10 = Severe)
Hot flashes / night sweats (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Breast tenderness (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Mood swings / irritability (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Anxiety / depression (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Decreased sex drive / Low libido (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Painful sex (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Difficult to climax sexually (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Vaginal dryness (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Difficulty sleeping (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Brain fog / Memory loss (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Weight gain (especially midsection) (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Hair thinning / hair loss (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Migraines / severe headaches (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Joint pain / stiffness (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Dry skin / brittle nails (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Feel cold often (Number, Min: 0, Max: 10)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Family History
Have there been any significant changes to your family history since your last consultation?
(Required)
No
Yes
Please explain changes in family history.
Δ
Initial HRT – Male: Coming Soon
Follow-up HRT – Male: Coming Soon
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