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Compounding 101
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Weight Loss
Women’s Health
Bioidentical Hormone Replacement Therapy (BHRT)
Men’s Health
Testosterone Therapy
Erectile Dysfunction (ED)
Veterinary Compounding
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Contact Us
About Us
Compounding 101
Our Programs
Weight Loss
Women’s Health
Bioidentical Hormone Replacement Therapy (BHRT)
Men’s Health
Testosterone Therapy
Erectile Dysfunction (ED)
Veterinary Compounding
Retail Pharmacy
Order Online
Contact Us
Telehealth Questionnaire
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I agree to allow my personal medical information to be distributed to a licensed prescriber.
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I agree that my prescriber will send any prescriptions to Stroud Compounding & Wellness Drugstore if applicable.
*
Yes
No
If you do not agree to the above, we recommend you contact your personal physician for a prescription and request they use Stroud Compounding & Wellness Drugstore. Thank you.
Contact Information
Name
*
First
Last
Email
*
Phone
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Basic Medical Information
Age
Gender
Height
Weight
I'm interested in prescriptions to address the following
*
Weight loss and/or diabetes
Hormone Replacement
Erectile Dysfuntion
Testosterone Therapy
Other
Additional Medical Information
Please list your current medications or supplements you are using.
Do you have any allergies or adverse reactions to medications? If so, please list below.
Please describe your symptoms or medical issue.
Weight Loss or Diabetes
Have you been diagnosed with diabetes or pre-diabetes?
Yes
No
Please specify type and duration.
Do you have a family history of diabetes or other metabolic disorders?
Yes
No
Please provide details of your family medical history.
Are you currently taking any GLP-1 treatments?
Yes
No
I’m not sure
Please specify which GLP-1 treatment you are taking.
How would you describe your current diet and physical activity level?
What other symptoms or issues are you experiencing related to your weight or diabetes diagnosis? Has any physician recommended that you lose weight?
Is there any other relevant information to weight loss or diabetes we should know?
Bioidentical Hormone Replacement Therapy (BHRT)
What symptoms are you experiencing related to your hormone levels?
Is there any other information to we should know related to BHRT?
Erectile Dysfunction
Are you experiencing difficulty getting or maintaining an erection?
Yes
No
Please provide more details that may be relevant to ED.
Have you had a heart attack, stroke, or other cardiovascular disease?
Yes
No
Please describe your cardiovascular events.
Testosterone Therapy
What symptoms are you experiencing that you attribute to low testosterone?
Is there any other information to we should know related to your testosterone levels?
Comments
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