Women’s Health Compounding Survey Compounded for you in 4 easy steps Contact Details First Name Last Name Contact Number Your Email Date Of Birth Which Method of Communication do you prefer? PhoneSMSEmailIn Person Medical History Do You Currently Have any Allergies? YesNo 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) Number of pregancies (0 if none) Number of children (0 if none) Lifestyle Are you trying to fall pregnant? YesNo Do you commonly experience episodes of sleep disturbance? If yes, how often in a week? Do you feel fatigued? YesNo Do You experience hot flushes? YesNo Do you experience joint or muscular pain? If yes, please specify. Do you experience loss of memory, or forgetfulness? YesNo Would you like to lose body weight? YesNo Do you experience headaches or migraines? YesNo Is mental health important to you? YesNo Do you need support in addressing hair loss? YesNo 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.