Hormone/Wellness Female Follow Up Form - Cobb Wellness and Aesthetics

Name: *

How are you doing overall? *

Is there something you want to improve? If so, please describe. *

Are you taking your hormone medications as Dr. Kelley had prescribed? *

What medications and dosages are you taking? *

What supplements are you taking and how? *

Last menstrual cycle if you are still having a cycle: *

Last PAP and Pelvic Exam? *

Last breast imaging: *

Last bone density: *

Last Colonoscopy? *

Primary care doctors info: *

Any other last testing from primary care? *

Estrogen imbalance *

Progesterone imbalance *

Testosterone imbalance *

Thyroid imbalancing *

Please check off any symptoms you are experiencing: *

Have you answered all the questions to the best of your knowledge? *