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Scheduled Appointment Form
 
 
 
 
 
Consult Options
 
 
 
 
 
 
Qualifying Questions
(Please record answers in the notes section)
 
Female
1. Have you had a hysterectomy? If so, was it a partial or complete?
2. Have you had an ablation?
3. When was your last pregnancy?
4. Have you received any type of hormone diagnosis from a previous physician?
5. Are you having menses regularly?
6. Do you currently have an IUD? If you have in the past, when was it removed?
 
Male
1. Have you ever tested low for testosterone?
2. What are your main concerns that are causing you to seek therapy?
3. Do you have a primary care physician? Are you annually having your physicals done?