Resource Hub | Survey Template | Compounding Chemist

Customer Contact Information

First Name

Last Name

Phone Number

Date of Birth

Gender

Which Method of Contact do You Prefer?

Phone Call SMS Email

Medical History

Do You Currently Have any Allergies?

Yes No

List of Current Medications. Please Include Supplements (If Any)

Do you have any family history of cancer, heart disease or diabetes? (Please state which one/s)

Lifestyle

Are you trying to improve your body composition? (E.g. Improve Muscle gain, lose body fat)

Yes No

Do you commonly experience episodes of sleep disturbance? If yes, how often in a week?

Do you feel fatigued?

Yes No

Do you experience joint or muscular pain? If yes, please specify.

Do you experience loss of memory, or forgetfulness?

Yes No

Would you like to lose body weight?

Yes No

Do you experience headaches or migraines?

Yes No

Is mental health important to you?

Yes No

Do you need support in addressing hair loss?

Yes No

Would you like to improve your libido or testosterone levels?

Yes No

Would you like to improve your strength?

Yes No

Permission to Contact

West Lindfield Pharmacy may not prescribe medications. Recommendations made by our team of pharmacists must be approved by your Doctor or Family Practice.

By clicking Send Now you permit West Lindfield Pharmacy to contact you to discuss a personal hormone plan to meet your health and lifestyle needs.

Fill Out Your Health & Wellness Survey For a Tailored Compounding Plan!

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