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

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Hormone Questionnaire for Women

Home / Hormone Questionnaire for Women

Female Hormone Questionnaire

"*" indicates required fields

Name*

First Last

Email*

Phone*

I prefer to be contacted by:

Phone

Text

Email

Address*

Street Address Address Line 2 City State ZIP Code

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.

Acne

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

Migraines

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 fibroids

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 current or previous hormone replacement methods and when you last had a treatment.

Have you ever been pregnant or given birth?

No

Yes

Are you trying to conceive?

No

Yes

Are you currently using a form of hormone contraception (pills, implant, ring, etc.)?

No

Yes

Do you still have your uterus?

Yes

No

What year (and month, if known) was your last period?

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.

If you are currently on hormone replacement therapy, what is the reason you'd like a consultation?

Date

MM slash DD slash YYYY

Comments

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Reviews

Skinspirations

4.9

Based on 264 reviews

See all reviews

Laura Gillis

1713721114

Dr Chase is amazing, she is very professional and honest. Can’t say enough positive... things about this practice.read more

Margaret Grosz

1713454523

Love the office. Kind, caring, knowledgeable and talented! Excellent results.

Amy Hawkins

1713358162

I've been going to skinspirations for many years. Dr Elliott is very skilled and... knowledgeable and listens to her patients needs. I wouldn't trust anyone else to take care of my skin.read more

Diane Clukey-Chenard, LCSW

1712840448

I have been going to Skinspirations for about 15 years. I adore all the folks that work... there and trust that they have my best interest at heart. They are kind, professional, and talented (did I mention funny, beautiful, and smart). I can't say enough about how wonderful they have been to me and so many others through the years.read more

teriwood18@yahoo.com 123Heather

1710883866

I love Skinspirations! I’ve had Botox at many places and this is by far the best!! Dr... Elliot is amazingread more

Laurie McConnaughey

1710252000

I moved to Florida from New York a couple years ago. I was with my previous aesthetician... for years in New York, so for me it was very stressful to find a new one, as I took regular care of my skin for years. After searching for about a year I found skinspirations. I recently met with Melissa for a micro needling procedure. Her technique as well as her knowledge of this procedure was incredible. I could not be happier with the results and I am so glad that I have found a place that I feel comfortable in knowing they are educated and so professional with what they do. I feel like she took care of me as she would herself and that is not always easy to find. Thank you skinspirations!read more

Angela Booe

1710074121

Dr Chase was wonderful! Answered all my questions and really helped me understand what... all my options are. Thank you!read more

CA

1709563653

Doctor Elliott is great! I’ve been to her throughout the years for a few different... procedures. She’s knowledgeable, personable, and truly cares about you as a patient!read more

Kyle Rabin

1709159321

The staff at Skinspirations was wonderful. It was my first time coming in after being... referred by a friend. I was in and out in less than 40 mins. Kate Dellangelo put me at ease and was so knowledgeable about all the services offered. Can’t wait to see my results and look forward to coming back.read more

Deborah Resnick

1708540378

Dr. Elliott and Skinspirations are a great benefit for those of us who live and work... close enough to avail themselves of the many amazing offerings in their office. Kate who does my Botox is a skilled at injections and there is never any discomfort or bruising and it is always perfect. Robin too is a terrific asset at scheduling and getting you in when it works for you. The office is so clean and lovely it is very pleasant. I have been a patient for over 20 years, I have moved to another city twice but always return to Skinspirations.read more

Lisa Zimmer

1707489195

Dr.Elliott was very thorough in our consultation, offering me more options for areas that... concerned me. I was prepared to have more done, to get the best results, and was pleasantly surprised by what she suggested was far less than I anticipated I needed. She has a discerning eye for perfection and I was very pleased with my results.read more

Janet McCreary

1707317447

I had an IPL facial. Staff is extremely professional and courteous. Melissa is very... knowledgeable and professional. I highly recommend Skinspirations and Melissa as an esthetician!read more

Kristine Cox

1703603594

I had a consultation with Dr.Chase for Botox and it was the most in depth consult I’ve... ever had. She is very knowledgeable and has many years of experience with Botox. I was extremely comfortable with her and my results are perfect.read more

Michelle M. Cook (Mimico)

1702764363

LOVE LOVE LOVE the team at Skinsperations. Dr. Elliott is amazing and funny. Not only are... you getting g the services you want and need you laugh while getting it done. They are the best.read more

K Hanson

1702138166

I always have a pleasant experience at Skinspirations. The entire staff is friendly and... helpful. I recently was treated by Kate and she does miracles.read more

Jean Mulrine DeMange

1701556701

Have always had great service from Skinspirations, whether it is facials, fillers or... other related services. Dr. Elliott has been my go to person since 2008. Gail has done my facials forever and her understanding of facial issues is astounding, she always fixes the issues which I think are unfixable. So many places have cropped up around town but I won't change since there needs to be a medical based practice involved with fillers, botox and aesthetics and that is what Skinspirations is from the beginning till today.read more

Keely Murphy

1701302495

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

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

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Skinspirations

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