13577 Feather Sound Dr., Suite 350 Clearwater, FL 33762 Call us at: +727 571 1923 Text us at: +727 263 4798 info@skinspirations.com

Home
About Us
Services
Concerns
Gallery
News
Shop
- Holiday Gift Card Special
  - Skinspirations Gift Cards
- Skin Care Products
Contact Us

Hormone Questionnaire for Women

Home / Hormone Questionnaire for Women

Female Hormone Questionnaire

"*" indicates required fields

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth (required by pharmacy)*

MM slash DD slash YYYY

Name of your primary doctor or gynecologist

Please check the symptoms you are currently experiencing.

Anxiety

Breast tenderness

Decrease in orgasm frequency or intensity

Decreased sex drive/libido

Depressed mood or less excitement about life

Difficulty concentrating

Difficulty sleeping

Dry, crepey skin

Fatigue or frequently tired

Hot flashes

Increase in belly fat

Irritability

Joint or back pain

Loss of lean muscle

Loss of strength or endurance

Night sweats

PMS 7-10 days before periods

Thinning hair

Urinary leakage

Vaginal dryness

Please check any medical conditions below for which you have been treated.

Anxiety or depression

Autoimmune or connective tissue disease (please specify type below)

Breast cancer

Other cancer (please specify type below)

Endometrial polyps or leiomyoma

Endometriosis

Fibrocystic breasts

Ovarian cysts or PCOS

Thyroid disease (please specify type below)

Uterine fibroids

Other (please specify type below)

Type of condition checked above

Please list any previous hormone treatments or birth control use with dosages if known and when they were last taken.

Have you ever been pregnant or given birth?

No

Yes

Are you trying to conceive?

No

Yes

What was the month and year of your last pap smear?

What was the month and year of your last mammogram?

If you have a copy of either of the above results or any hormone labwork done within the last year, please upload them here.

Max. file size: 16 MB.

Name

This field is for validation purposes and should be left unchanged.

Reviews

Skinspirations

4.9

Based on 251 reviews

See all reviews

Laurie

1700433363

I’ve been a Skinspirations client for more than 14 years. Here, you'll find knowledgable,... professional, caring staff who offer the most innovative procedures and techniques to enhance each individual's features. Dr. Elliot is remarkably adept at listening to and treating all areas of concern. Skinspirations is the BEST!!!read more

Angie Young

1699483249

Best Botox place ever!!! The staff is so friendly and very nice place.

Julianne Gilberti

1697930082

DR. Elliot is professional, caring and conservative with treatment. Always a great... experience.read more

Alicia Sorenson

1696367822

With each visit, I have been consistently impressed with the entire staff at... Skinspirations. They are professional, courteous and take the time to discuss the patient's particular needs and desired treatment program/goals. My results have been exceptional. I highly recommend!read more

Annette Dietzer

1694383540

This week Dr. Elliott did an AMAZING subcision and filler session on my acne scars! I've... lived with these scars for many decades, and they were just getting deeper as I aged and my face lost volume. My experience wasn't like those you see on videos. It was painless as Dr. Elliott skillfully and delicately released the tetherings of my scars, and added filler to prevent future tetherings as my face heals. She has a wonderful bedside manner and talks you through the whole procedure. If you want a change for the better, see Dr. Elliott.read more

Jennifer

1693860056

Great office and staff - professional, very knowledgeable. They help you make informed... decision as to products and procedures. No pressure or sales driven tactics. They listen to what you want and work with that approach. I wouldn't go anywhere else. Love this office and this staff - incredible all the way around. Outstanding results.read more

Jane Strigler

1693781758

LOVE SKINSPIRATIONS! My skin has never looked better. I’m 73 and ppl mistake me for being... on early 60’s. Yes, some is genes but Skinspirations has eliminated all brown spots with one ablative laser treatments. They are the best. In addition to being knowledgeable their prices are lower than anyone else.read more

Audrey Beitzel

1693527135

Such a find. Wonderful, personalized services and consultations. So excited to try more... services. Fabulous staff from beginning to end. Highly recommendread more

Sissy Spain

1689862453

Great atmosphere and everyone is very friendly! Kate is great!

Jean Magee

1689086284

I thoroughly enjoy going to Skinspirations and have for many years. All staff members... are professional, well-trained, and pleasant. Melissa Kennow has been "my" esthetician for quite a few years now. She is extremely knowledgeable, gentle, and dedicated to achieving the best results for her customers. I truly value her advice and look forward to our sessions.read more

Katherine LaFever

1688086426

Would totally recommend this place and Kate specifically! I went in for a lip flip and I... love how it has turned out, I will definitely be back. Last time I had botox at a different place, I fainted but the girls at Skinspirations helped me be relaxed and gave me an icepack and stress ball.read more

Cynthia A Cline

1686265506

The view from the window is so incredibly calming along with the music. Makes an... unpleasant procedure much less unpleasant. The staff are fantastic and so helpful. My tech is amazing and incredibly skilled at what she does. I was referred here by a friend who highly recommended them and now I have been a client for a couple of years myself.read more

Pool Business

1685665320

Dr. Elliot is exceptionally skilled and personable. The staff is pleasant and... accommodating. Highly recommend.read more

karley a

1684704824

Dr. Elliot is wonderful! She takes time to listen to my concerns and shares knowledge... about the products and how they work with my body. I am so pleased with the service there!read more

Angé Peterson

1682610612

Great professional service with the latest products and technologies-definitely worth my... drive over.read more

Florence Wunderlin

1682377458

Dr Elliott is amazing her technique is perfect the staff is friendly and Gale is the best... aesthetician. I always walk out of there office feeling wonderful.read more

Patricia Caldwell

1681939294

It's always a pleasurable visit at Skinspirations. The Office Staff makes you feel right... at home and I can't say enough aboutDr, Elliott. You may not think you look so good going into thevisit, but thanks to Dr.Elliott's expertise you will look and feel great afterwards.read more

marie berilla

1676421823

This is the place to go for all your skin care needs. The staff is amazing. It is like... having your own personal skin care consultant. The medical grade facials are worth every penny and sure to give you great results.read more

Flora C

1676157445

My esthetician Gale has provided me with amazing results for the last 15 years. She’s... extremely knowledgeable and professional in all aspects of her profession. The atmosphere is very relaxing with soothing music in the background. This MedSpa is by far the best!read more

D Bormann

1675613430

Top Notch Professionals!Love Dr. Elliot! The office is great - staff is wonderful... -Always help you get just what you want or need!read more

Martha Lamelas

1673988040

I am very happy with Dr. Elliott’s work. She is smart and a caring person. I highly... recommend her for any work she provides in her office.read more

Liz

1671460775

I’ve had services at other facilities and can tell you that Skinspirations is top quality... for providers and services. Dr Chase does my injectable’s and she’s excellent. I highly recommend.read more

Malou Bautista

1670174299

It was my first time at skinspiration upon recommendation of a friend. I was very... impressed with the reception, and mostly the consultation that I spent with Melissa. She was very knowledgeable and helpful in explaining the type of my skin and what recommendations she has to offer me. I had the hydra facial done, and it was great. I highly recommend to anybody.read more

Rachael Gordon

1669903616

Top notch service, from the moment you walk in till the time you leave. Kate is the best... and she takes her time and helps you through what your best options are that best fits you. Very happy and already have next appointment booked.read more

Valerie Hightower

1669427860

Love them been going several years, always a pleasant experience

Sara McConnell

1669047034

Atmosphere is calming. I was anxious going in and Kate made me feel much better and... confident in my choice!read more

Amanda Payne

1668428803

First time at skinspirations and I got the hydra facial! It was amazing! The staff was... super friendly and professional! Definitely will be back!read more

Keely Murphy

1668117738

I was recommended by another esthetician, which is impressive to start. All through the... appointment process on line, follow up call, lovely office visit and painless injections, this was a pleasurable experience. I found myself anxious for more self improvements, due to my new Medi Spa service find with Skinspirationsread more

Keely Murphy

1668111616

Friendly greeting, personalized attention and professional beautiful staff. I want what... they have, for myself, so I’m loyal to Skinspirations!read more

Oz Mendez

1667659705

I love love love the team at Skinspirations! They provide the best quality service and... always make me feel special!read more

Mary McKenna

1667142839

Visiting Skinspirations is always a pleasant experience. Dr. Elliott is amazing & her... staff are all very friendly and professional. I'm always happy with the results of my treatments. Retuned again for another procedure recently & it was a very enjoyable experience - the staff & Dr Elliot are fantastic! Wouldn't go anywhere else!read more

Darlene Hutton-Pavoni

1665879577

I have been coming to Inspirations for several years and each time I am there the staff... is warm and very professional ! Dr Elliot is amazing!! She advises me what her thoughts are on which procedure might be better for me after our discussion . Always makes me feel very special and looking good when I leave . Quality is everywhere in this office. I love the soft music playing and it creates a relaxing atmosphere.read more

pratigya sharma

1662915619

Gale and all the other staffs were immensely kind and wonderful! Great service with... excellent attention to details. Thankyou so very much!read more

Kyle Jetton (VKFlorida)

1662128192

Great staff and very pleased with the results... couldn't be any happier.

Dany P

1661878532

Professional, friendly staff! Felt well looked after. Can only recommend this place!

Laurie Muldowney

1661168416

Staff was friendly and helpful with everything I will highly recommend anyone interested... in their servicesread more

D Miles-McCray

1660489710

Skinspirations is my only go to skincare center to get the best services from kind... providers,. Gale, thank you for taking great care of my skin!read more

Diane Stein

1660319963

I have been coming to Skinspirations for years and absolutely love them! Dr. Elliot is a... real artist when it comes to helping you achieve your desired look and her staff are amazing. Each is a professional in their own right and the team as a whole instill confidence their ability to provide excellent service and results.read more

Karla Ravenel

1657898358

I did my research and took a gamble- Kate, Lisa, and all the ladies here are amazing and... do such a great job of seeing what needs to be done, doing it and even make it entertaining. They are so thoughtful and did such an amazing job that I will definitely keep going back! They fit me in on short notice to accommodate my schedule and really give you results. What more could you ask for.read more

Jacqueline Dolan

1657543823

I’ve had four fiber-blast treatments. Very happy with the results. I get complements... all the time on my skin. Thanks Galeread more

Sherry

1656712016

Dr. Elliot and the entire staff at Skinspiration are amazing! Very knowledgeable and... they take their time with you. I didn’t feel rushed and most importantly very happy with my treatment.read more

Next Reviews

REQUEST CONSULTATION

Skinspirations

Main Office 13577 Feather Sound Drive, Suite #350 Clearwater, Florida 33762 727.571.1923 727.263.4798
Business Hours

Shipping & Returns

https://www.skinspirations.com/shipping-returns/

Please Note: Procedure results vary greatly from patient to patient and are not guaranteed. The photos on this website are not intended to represent the results that every patient can expect. The information on this site is intended for general purposes only and is not intended to nor implied to be a substitute for professional medical advice relative to specific medical conditions or questions.