Family History: List Important Diseases
Have you had any of the following surgeries?
Have you ever used any of the following birth control methods:
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.
Please select 3 times that work best for a phone consultation with one of our pharmacists.
Our times offered are Monday - Friday with time blocks from 9:00am-12:00pm, 12:00pm-3:00pm or 3:00pm-6:00pm. Consults typically last between 30 minutes and one hour. We will check availability and get back with you with a specific time.