Moudry Rx-Compounding Lab Test Questionnaire
Preferred method of contact
(heart disease, thyroid, high cholesterol, diabetes, cancer, hormonal issues, depression, high blood pressure, other)
High Blood Pressure
Please specify other medical conditions
Do you have symptoms of hormone imbalance?
(weight gain, hot flashes, night sweats, mood swings, depression, low libido, insomnia, fatigue, memory loss, vaginal dryness, headache)
(muscle loss, weight gain, fatigue, sleep problems, hot flashes, night sweats, low sex drive, irritability, depression, hair loss, ED, memory loss)
Lower sex drive
Are you currently taking hormone replacement?
If yes, please list medications and route of administration (topical, oral, sublingual, etc...)
Have you had your vitamin D level checked in the past year?
If yes, what is that level?
Are you currently taking vitamin D supplementation?
If yes, please list supplements
Do you have concerns of thyroid dysfunction?
(cold, weight gain/loss, constipation, fatigue, headache, anxiety, dry skin, brittle nails, hair loss)
Are you currently being treated for thyroid dysfunction?
Are you taking thyroid medication?
If yes, please list medication
Have you had the following tested?
(FT3, FT4, TSH, TPO, Reverse T3)
Are you interested in further thyroid testing?
Do you have concerns of adrenal fatigue? (Stress, sleep, serious fatigue)
If yes, check all that apply
Overwhelmed easily by everyday tasks
Catching more colds than before
Using coffee or chocolate to get through your day
Crave unhealthy food
Have no energy by middle afternoon
Gaining weight around the middle
Drinking more alcohol to relieve stress
Aches and pains linger longer
Are you on Medicare?
Do you need a form to submit to your insurance for possible reimbursement?
FSA/HSA can be used
Would you like to receive emails regarding Moudry's upcoming events/promotions? We do not share your information.
Are you concerned with: (please check all that apply)
Anxiety and Panic Disorder
who referred you to us for testing?