Complete the online form below.

Once received, we will contact you to schedule your hormonal consultation either in person or by phone.

Allow at least 24 hours for us to complete your request. 

CONFIDENTIAL HORMONE EVALUATION

Do you use tobacco?
Do you use alcohol?
Do you use caffeine?
Do you exercise?
Are you sexually active?
Have you ever used oral contraceptives (birth control)?
Any Interrupted pregnancies?
Have you had a tubal ligation?
Have you had a hysterectomy?
Do your ovaries remain?
Have you had any of the following tests performed?
Mammography
PAP Smear
Bone Density
Any clots?
Have you ever had what YOU would consider to be abnormal cycles?
Do you or have you ever suffered from Premenstrual Syndrome (PMS) symptoms?
Hot Flash
Night Sweats
Vaginal Dryness
Incontinence
Bleeding Changes
Fibrocystic Breast
Weight Gain
Fluid Retention
Dry Skin/Hair
Hair Loss
Anxiety
Depression
Mood Swings
Irritability
Headaches
Breast Tenderness
Cramps
Difficulty Falling Asleep
Difficulty Staying Asleep
Fatigue
Loss of Memory
Foggy Thinking
Acne
Arthritis
Decreased Sex Drive
Harder to Reach Climax
Stress

11720 Medlock Bridge Rd. Suite 162
Johns Creek, GA 30097

PH: 770.622.8901
FX: 770.622.8900

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A prescription from a licensed practitioner is required for compounded medications.

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