• What is your height?

• What is your weight?

• What is your blood pressure?

• Do you smoke?

• Have you had any cardiovascular (heart) problems or have you ever had a stroke?

• Can you walk 3 miles or climb a set of stairs without pain in your chest?

• Do you suffer from any allergies?

• Please provide further details about your allergies.

• Are you currently taking any other medication?

• Please provide the exact name and dose if available.

• Is there a history of any disorder that has run within your family?

• Please provide more information, including as much detail as possible.

• Have you ever had any major surgery?

• Please provide further details of surgery undergone, including any relevant dates.

• Do you suffer from decreased libido (lack of sex drive), if so, what are your symptoms?

• Please provide more information, including as much detail as possible.
  

• Has your uterus been removed?

• 
  

• Are you currently taking any hormonal medicines (such as HRT)?

• Please provide more information, including the names of any medications currently taken.
  

• From the below list, please select the option that's most applicable to you:

• 
  

• Have you been diagnosed by your doctor as having low levels of female sex hormones?

• Please provide more detail, providing as much information as possible.
  

• Do you currently have or have you previously had breast cancer?

• Please provide more detail, providing as much information as possible.
  

• When were you last checked for breast cancer?

• 
  

• Do you suffer from liver disease?

• Please provide more detail, providing as much information as possible.
  

• Do you suffer from kidney disease?

• Please provide more detail, providing as much information as possible.
  

• Do you suffer from heart disease?

• Please provide more detail, providing as much information as possible.
  

• Is there any other medical information relevant to your condition that you think our doctor should consider?

• Please provide more information, giving as much detail as possible.
  

• I understand that I should not use this treatment if I am pregnant.

• 
  

• I understand that anyone pregnant must not come into contact with my medication, if prescribed.

• 
  

• I understand I need to take concurrent oestrogen treatment with Intrinsa, and will source that from my regular doctor.

• 
  

• Have you recently finished taking any medications?

• Please provide the exact name and dose if available.
  

• It is in your best interest if our prescribing doctor can share information with your regular GP. Do you wish for us to share this information with your GP?

• Please provide the name & address of your current GP.