If you are interested in having Yakim's Compounding Pharmacy evaluate your hormone needs and contact your physcian or prescriber, please fill in the following questionnaire.  If you have difficulty, please, don't hesitate to call us.
Natural Hormone Replacement Questionnaire
* Name
* Street Address
   Street Address (page two)
* City
* State
* Zip Code
* Phone Number
* Email Address
* Date of Birth
* Weight
* Height
* Waist Measurement
* Hip Measurement
* Body Frame
* List All Current Medications, Hormones and Supplements
   List Allegies to Food or Medications
   List all Prior gynecological surgeries, including date
   List all Current and Previous gynecological diagnosis
   List all Current and Previous Cardiac Complications
   List all Other Previous and Current Medical Conditions
* Sleep Disturbances
* Hot Flashes
* Skin Changes
* Changes in Mental Function
* Vaginal Changes
* Breast Changes
* Changes in Hair
* Changes in bladder/bowel function
* Weight fluctuations
* Sexual Dysfunction
* Do you use caffeine productsYes No
   How much caffeine
* Do You Use AlcoholYes No
   How Much Alcohol
* Do You Use Tobacco ProductsYes No
   How Much Tobacco
* Do You ExcericseYes No
   How Much Excercise
* Number or Pregnancies
* Number of Births
* Age of First Period
   Age of First Pregnancy
* History of Heart Disease
* History of Fibroids
* History of Breast Cander
* History of Osteoporosis
* Physician's Name
* Physician's Phone Number
* What is Your Worst Symptom
   Goals of Therapy
   Comments
* How were you referred to us
* When the pharmacist has an option, do you prefer oral or transdermal medication? Sometimes the condition dictates the choice but often times, there is a choice.
* I have read the permission statement belowYes No

By submitting this information to Yakim's Compounding Pharmacy, you are authorizing Yakim's Compounding Pharmacy to discuss this with appropriate healthcare providers including your provider.  After receiving your questionnaire, Yakim's Compounding Pharmacy will contact your presriber with our written recommendation.  Yakim's Compounding Pharmacy will then contact you, via telephone, after receiving a response from your prescriber.