Every woman we talk to has questions about her hormones. We are here to help.

A great first step in understanding your hormones and your body is to fill out our questionnaire. Please complete the questions below with as much information as possible. All information is transmitted securely. Once we have received your information, a Coast to Coast Compounding pharmacist / representative will contact you about the next steps that are appropriate for your situation.

We offer a multitude of options including doctor referrals, consultations, blood work and free educational seminars.  

Complete your survey today.

 
CONTACT INFORMATION
Name *
Name
Address
Address
Primary Phone
Primary Phone
BIOGRAPHICAL INFORMATION
Date of Birth
Date of Birth
HEALTH HISTORY
(include dates)
If Yes, Full (uterus and both ovaries) or Partial (describe) and Date of Surgery
Yourself: Yes, No (if yes, type of cancer) / Family Member: Relationship and Type
Yourself: Yes, No Family Member: Relationship
Mother: Father:
LIFESTYLE
Activity and times/week
Do you smoke?
Yes or No; if Yes, Frequency
Yes or No; if Yes, Frequency
MEDICATIONS
CURRENT SYMPTOMS
Choose the number that best fits the symptoms you are experiencing: 0 = None 1 = Mild 2 = Moderate 3 = Severe
Hot Flashes
0 = None 1 = Mild 2 = Moderate 3 = Severe
Heart Palpitations
0 = None 1 = Mild 2 = Moderate 3 = Severe
Hair Loss
0 = None 1 = Mild 2 = Moderate 3 = Severe
Dry or Brittle Hair
0 = None 1 = Mild 2 = Moderate 3 = Severe
Anxiety
0 = None 1 = Mild 2 = Moderate 3 = Severe
Depression
0 = None 1 = Mild 2 = Moderate 3 = Severe
Tearful
0 = None 1 = Mild 2 = Moderate 3 = Severe
Nervous
0 = None 1 = Mild 2 = Moderate 3 = Severe
Mood Swings
0 = None 1 = Mild 2 = Moderate 3 = Severe
Foggy Thinking
0 = None 1 = Mild 2 = Moderate 3 = Severe
Headaches
0 = None 1 = Mild 2 = Moderate 3 = Severe
Memory Lapse
0 = None 1 = Mild 2 = Moderate 3 = Severe
Decreased Libido
0 = None 1 = Mild 2 = Moderate 3 = Severe
Dry or Irritated Eyes
0 = None 1 = Mild 2 = Moderate 3 = Severe
Aches & Pains
0 = None 1 = Mild 2 = Moderate 3 = Severe
Constipation
0 = None 1 = Mild 2 = Moderate 3 = Severe
Acne
0 = None 1 = Mild 2 = Moderate 3 = Severe
Bone Loss
0 = None 1 = Mild 2 = Moderate 3 = Severe
Tender Breasts
0 = None 1 = Mild 2 = Moderate 3 = Severe
Fibrocystic Breast
0 = None 1 = Mild 2 = Moderate 3 = Severe
Increased Urinary Urge
0 = None 1 = Mild 2 = Moderate 3 = Severe
Vaginal Dryness
0 = None 1 = Mild 2 = Moderate 3 = Severe
Evening Fatigue
0 = None 1 = Mild 2 = Moderate 3 = Severe
Unable to Fall Asleep
0 = None 1 = Mild 2 = Moderate 3 = Severe
Unable to Stay Asleep
0 = None 1 = Mild 2 = Moderate 3 = Severe
Night Sweats
0 = None 1 = Mild 2 = Moderate 3 = Severe
Morning Fatigue
0 = None 1 = Mild 2 = Moderate 3 = Severe
THANK YOU
We will review your information, and contact you to schedule a consultation.