Moudry Rx-Compounding Lab Test Questionnaire
Date
Name
Birthdate
Address
City
State
Zip
Phone
Email
Preferred method of contact
Phone
Email
Gender
Female
Male
Height
Weight
Doctor's Name
Doctor's Address
Doctor's Phone
Medical Conditions
(heart disease, thyroid, high cholesterol, diabetes, cancer, hormonal issues, depression, high blood pressure, other)
Heart Disease
Thyroid Disease
High Cholesterol
Diabetes
Cancer
Hormonal Issues
Depression
High Blood Pressure
Other
Please specify other medical conditions
Do you have symptoms of hormone imbalance?
Women
(weight gain, hot flashes, night sweats, mood swings, depression, low libido, insomnia, fatigue, memory loss, vaginal dryness, headache)
Weight gain
Hot flashes
Night sweats
Mood swings
Depression
Low libido
Insomnia
Fatigue
Memory loss
Vaginal dryness
Headache
Men
(muscle loss, weight gain, fatigue, sleep problems, hot flashes, night sweats, low sex drive, irritability, depression, hair loss, ED, memory loss)
Muscle loss
Weight gain
Fatigue
Sleep problems
Hot flashes
Night sweats
Lower sex drive
Irritability
Depression
Hair loss
Erectile dysfunction
Memory loss
Are you currently taking hormone replacement?
Yes
No
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?
Yes
No
If yes, what is that level?
Are you currently taking vitamin D supplementation?
Yes
No
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)
Cold
Weight gain
Weight loss
Constipation
Fatigue
Headache
Anxiety
Dry skin
Brittle nails
Hair loss
Are you currently being treated for thyroid dysfunction?
Yes
No
Are you taking thyroid medication?
Yes
No
If yes, please list medication
Have you had the following tested?
(FT3, FT4, TSH, TPO, Reverse T3)
Free T3
Free T4
TSH
TPO
Reverse T3
Are you interested in further thyroid testing?
Yes
No
Do you have concerns of adrenal fatigue? (Stress, sleep, serious fatigue)
Yes
No
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
Angry often
Crave unhealthy food
Have no energy by middle afternoon
Gaining weight around the middle
Easily irritated
Drinking more alcohol to relieve stress
Aches and pains linger longer
Restless sleep
Are you on Medicare?
Yes
No
Do you need a form to submit to your insurance for possible reimbursement?
FSA/HSA can be used
Yes
No
Email
Would you like to receive emails regarding Moudry's upcoming events/promotions? We do not share your information.
Yes
No
Are you concerned with: (please check all that apply)
Fatigue
Menopause
Weight Control
Depression
Insomnia
Hormones
Migraines
ADHD
Premenstrual
Anxiety and Panic Disorder
Autism
Gastrointestinal Complaints
Immune Condition
Addiction
Mood Imbalance
Trouble Sleeping
Other
who referred you to us for testing?