3100 Cross Creek Parkway Suite 220, Auburn Hills, MI 48326 |
(248) 325-8549
ABOUT US
ABOUT US
About US
Our Mission & Vision
FAQ
FOUR PILLARS
FEATURED SERVICES
FEATURED SERVICES
HORMONE REPLACEMENT THERAPY
WEIGHT LOSS
GUT HEALTH & MICROBIOME RESTORATION
TED HAIR RESTORATION
COUNSELING & COACHING
QUESTIONNAIRE
QUESTIONNAIRE
Tahki Institute Patient Intake Form
Health Symptoms Questionnaire
GI Health Appraisal Questionnaire
Male Hormone Questionnaire
Female Hormone Questionnaire
BLOG
Contact Us
ABOUT US
About US
Our Mission & Vision
FAQ
FOUR PILLARS
FEATURED SERVICES
HORMONE REPLACEMENT THERAPY
WEIGHT LOSS
GUT HEALTH & MICROBIOME RESTORATION
TED HAIR RESTORATION
COUNSELING & COACHING
QUESTIONNAIRE
Tahki Institute Patient Intake Form
Health Symptoms Questionnaire
GI Health Appraisal Questionnaire
Male Hormone Questionnaire
Female Hormone Questionnaire
BLOG
Contact Us
Female Hormone Questionnaire
Female Hormone Questionnaire
Patient Name
Patient DOB
Date
Check All That Apply
Fibrocystic Breast
Vaginal Dryness
Breakthrough Bleeding
Weight Gain
Headaches
Fatigue
Heavy / Irregular Menses
Irritability
Loss Of Memory
Hot Flashes
Mood Swings
Bladder Symptoms
Dry Skin / Hair
Arthritis
Breast Tenderness
Anxiety
Depression
Night Sweats
Sleep Disturbances
Cramps
Fluid Retention
Hair Loss
Decreased Sex Drive
Harder To Reach Climax
Patient Evaluation
Do you still have a menstrual cycle?
Yes
No
If so, when was the first day of your LMP?
Are you experiencing hot flashes?
Yes
No
If so, how often and how severe?
List any additional concerns you currently have:
Have you tried any therapies/medications already?
Yes
No
If so, include specific medications, doses, and frequency:
What was the outcome?
Submit Questionnaire