Submitting your questionnaire…

Health Questionnaire
Step 1 of 10
1
About you

Personal Information

All your information will remain confidential between you and Dr. Sharan's Clinic.
Birth date or age is required.
2
In case we need it

Emergency Contact & Social Information

3
Your history

Medical History

Tick anything that applies to you. Leave blank if none apply.

Family History
4
Care & medications

Surgeries, Allergies & Medications

Surgeries & Hospitalisations
Medication Allergies
Food Allergies
Prescription Medications
Supplements & Over-the-Counter
5
Screening & wellbeing

Screening & Personal History

5
1 – Low stress10 – Extreme stress
6
Daily life

Sleep & Fitness Lifestyle

7
How you feel

Hormone Symptoms

Tick any symptoms you experience. Leave blank if none apply.

8
Women's health

Women's Health – PCOS Evaluation

Optional — for female patients only. Men may continue to the next step.
3
1 – Very low5 – Very high
9
Food & drink

Nutrition Evaluation

10
Almost done

Additional Information & Consent

Consent – BHRT

I request and consent to the administration of hormones and oral supplements prescribed by my physician. I acknowledge there are no guarantees regarding the benefit of Bio-Identical Hormone Replacement Therapy (BHRT).


I understand initial blood tests will be performed to establish baseline hormone levels, and I agree to comply with ongoing testing and monitoring. I will communicate any adverse reactions to my physician and understand there are risks if I do not comply with recommended dosage.


I have not been promised any specific benefit. I understand BHRT for rejuvenation is a new specialty with no guaranteed outcomes.


I have read and understood the above, have received information about BHRT, and hereby request and consent to treatment using Bio-Identical Hormone Replacement Therapy.

Thank You!

Your health questionnaire has been submitted successfully. Dr. Sharan's Clinic will review your information before your appointment. If you have any questions, please contact the clinic directly.

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Thank You!

Your health questionnaire has been submitted successfully. Dr. Sharan's Clinic will review your information before your appointment. If you have any questions, please contact the clinic directly.

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