Consultation Form

Personal Information
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Address
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  5. (valid email required)
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  7. Do you use tobacco products
  8. Do you use caffeine products?
  9. Do you use recreational drugs
  10. Do you or any family member have cardiovascular disease?
  11. Do you have a history of cancer or in your family?
  12. Do you have trouble losing weight?
For Women Only
  1. » Click here for the men's questions
  2. Have you ever had an abnormal Pap?
  3. Do you still have your period?
  4. Do you have pain at any other time in your cycle?
  5. Any bleeding between periods (IMB):
Have you had any of the following surgeries?
  1. If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed?
  2. Have you ever been pregnant?
  3. Are you trying to get pregnant?
  4. Any interrupted pregnancies (miscarriages or abortions)?
Have you ever used any of the following birth control methods:
  1. Oral Contraceptives (Birth Control Pills)?
  2. Intra-Uterine Device (IUD)?
  3. Do you examine your breasts monthly)?
FOR MEN ONLY
  1. Have you noticed a decrease in muscle mass?
  2. Have you experienced difficulty in establishing and/or maintaining full erections?
  3. Do you have a decrease in spontaneous early morning erections?
Syptoms
  1. CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks. 0 = None (symptom not present) 1 = Mild (present but not distressing) 2 = Moderate (distressing, but not interfering with daily life) 3 = Severe (very distressing, interferes with daily life) If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.
  2. Hot flushes
  3. Night sweats
  4. Light-headed feelings/dizziness
  5. Headaches
  6. Sleep disorders/Sleeplessness
  7. Unusual tiredness/Fatigue
  8. Irritability
  9. Depression
  10. Anxiety/Tension/Nervousness
  11. Mood swings/Mood changes
  12. Confusion/Difficulty concentrating
  13. Forgetfulness/Short-term memory loss
  14. Angry outbursts/Arguments/ Violent tendencies
  15. Crying easily
  16. Backache
  17. Joint pains
  18. Muscle pains
  19. Muscle cramps/spasms
  20. Problems with wound healing time
  21. Acne/Pimples/Skin flushing
  22. New facial hair
  23. Dry skin/Dry hair
  24. Crawling feeling under skin
  25. Frequent Urinary Tract Infection (UTI)
  26. Urinary frequency
  27. Vaginal dryness
  28. Abnormal bleeding
  29. Pelvic pain, pressure, fullness, or bloating
  30. Uncomfortable intercourse
  31. Loss of sexual feeling/desire
  32. Loss of arousability & capacity for orgasm
  33. Loss of vitality
  34. Nipple sensitivity
  35. Discharge or leaking from nipples
  36. Breast tenderness
  37. Loss of pubic hair
  38. Swelling of hands, ankles, or breasts
  39. Heart palpitations
  40. Shortness of breath
  41. Food /sweets /salt cravings
  42. Increased appetite/weight gain
  43. Visual disturbance or decreased vision
  44. Difficulty hearing
  45. Diminished sense of taste
  46. Diminished sense of smell
Are you Human? Please answer this test question:
 

Contact Us

By Phone:  (941) 921-6645 or (888) 245-0070

By Fax: (941) 923-7558

By Email: Contact Us

Pharmacy Open to Public: Monday through Friday: 9am to 6pm

Call Center Hours: Monday through Friday: 9am to 6pm

CustomPetRx has moved to Family Pharmacy All CustomPetRx patient records and prescriptions have been transferred to our location. For any questions or concerns, please contact a pharmacy representative at 855-977-2779. Ask The Pharmacist  ask-the-pharmacist-cropLet us know how we can help you and your family. » ask the phamacist

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Sarasota's First and Only PCAB Accredited Compounding Pharmacy