Full Name *

Email *

Mobile phone *

Date of birth *

Sex at birth *

Female

Male

Which state do you live in? That is where a prescription would ship. *

Which of these bother you now? Check all that apply. *

Trouble falling asleep

Waking around 3 a.m. and staying awake

Anxiety

Irritability or rage

PMS that got worse

Crying spells or mood swings

Hot flashes

Night sweats

Brain fog (words, focus, memory)

Joint aches

Dry skin

Hair thinning

Low sex drive

Hard to reach orgasm

Vaginal dryness

Painful sex

Burning, urgency, or repeat UTIs

Tired in a way sleep doesn't fix

Low motivation

Slow recovery from workouts

Weight gain, or weight moving to your middle

Always cold

Constipation

Erections weaker or less frequent

Fewer morning erections

Loss of muscle or strength despite training

Belly fat gain

Low mood

Short fuse or irritability

Poor sleep

Loud snoring, or been told you stop breathing at night

Hair loss

How long have you felt this way? *

What is not working, or what do you most want to feel different? And why does that matter to you right now? *

What have you already tried? Check all that apply.

Have you had hormone blood work in the last 12 months? *

Yes

No

What were you told?

Upload your blood work (PDF or photo). Optional, up to 5 files.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Are you on any hormone treatment right now? *

Yes

No

Which hormone medicines do you take right now? For each one, tell us the name, the exact dose, how you take it, and how often.

What else do you take, such as thyroid medicine, blood pressure medicine, or supplements? For each one, tell us the name, the amount, and how often.

Have you ever had a blood clot in a vein or in your lungs, such as a DVT or a pulmonary embolism? If yes, when, and are you on a blood thinner? *

Yes

No

Not sure

Have you ever had a stroke or a mini-stroke? If yes, when, and what treatment did you have? *

Yes

No

Not sure

Do you have a history of breast, ovarian, uterine or prostate cancer? If yes, what type, when, and what is the current status? *

Yes

No

Not sure

Do you have liver disease now? If yes, what kind, and who treats it? *

Yes

No

Not sure

Do you have heart disease or a heart rhythm problem such as AFib? If yes, what is it, and how is it treated? *

Yes

No

Not sure

Do you have sleep apnea, or has anyone told you that you stop breathing at night? If yes, do you use a CPAP? *

Yes

No

Not sure

Do you smoke or vape nicotine? *

Yes

No

Quit

Are you pregnant or breastfeeding, or could you be pregnant? If yes or not sure, please tell us more.

Yes

No

Not sure

Have you had any unusual bleeding, such as bleeding after menopause or bleeding with no known cause? If yes, when, and has a doctor checked it?

Yes

No

Not sure

Which best describes your periods?

Do you still have your uterus?

Yes

No

Not sure

Do you want to have children in the future, or are you trying now?

Yes

No

Not sure

If you answered Yes or Not sure to any question above, please tell us more.

How would you like to have your consult? *

In person in Magnolia

In person in Cypress (by appointment only)

Telehealth (video)

What is the best time to reach you?

How did you hear about us?

I understand this form is not a diagnosis, and that a licensed provider decides whether any treatment is appropriate for me.

Optional: By checking this box, I agree to receive text messages from Made Ya Skinny, LLC dba My Life Optimized about my request and appointments. Message frequency varies. Message & data rates may apply. Reply HELP for help or STOP to opt out. Consent is not a condition of purchase.