bioidentical hormone replacement therapy bhrt eligibility intake form

Take the first step to improve your long term health

This intake questionnaire helps us determine your eligibility to join Dr. Elisabeth Crisci’s practice.

This form takes about 15 minutes to complete. Please note that not all applicants are suitable candidates. Completing this form does not commit you to become a member of Dr. Crisci’s practice.

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Your personal information is protected under the Canadian Personal Information Protection and Electronic Documents Act (PIPEDA).

DATA PRIVACY: Your personal information is used only to determine your eligibility for our treatment services, and is stored in a secured cloud database. If it is determined that you are not eligible, you can request the deletion of your personal data.

Please indicate your acceptance to proceed. *

I accept the privacy disclaimer.

First Name: (As it appears on your health card.) *

Last Name: (As it appears on your health card.) *

Email: *

Mobile phone: *

This allows us to send you security and login updates.

Do you agree to receive subsequent email communications from Pacifica MD? *

I agree.

British Columbia resident: *

I confirm that I am a resident of British Columbia, Canada.

Dr. Crisci is only licensed in the Province of British Columbia, Canada.

Address *

Address Line 1

City

Zip / Postal Code

Your Personal Health Number (Your BC Medical Services Card Number – back of your driver’s license or on your BCID) *

Please use format 1234123123, with no spaces or dashes

Name of your primary care provider physician: *

If you do not have one, please remark that above. Please note that Dr. Crisci does NOT replace your primary care physician.

Current Date / Timestamp (You do not need to enter anything into this field, this is automatic.)

Sex at birth: *

Female
Male

Please note that BHRT treatments from Dr. Crisci are designed to restore and balance natural hormones for women aged 20 to 65, and men aged 40 and older. These hormone treatments are not designed for those wishing to alter gender identity.

Birthdate: *

Year – Month – Day

Age (for confirmation) *

Symptom Questionnaire for Women

Breast tenderness *

None
Mild
Moderate
Severe
Very severe

Physical exhaustion / fatigue *

None
Mild
Moderate
Severe
Very severe

Sleep problems *

None
Mild
Moderate
Severe
Very severe

Decline in drive or motivation *

None
Mild
Moderate
Severe
Very severe

Anxiety *

None
Mild
Moderate
Severe
Very severe

Joint and muscular symptoms (aches and pains) *

None
Mild
Moderate
Severe
Very severe

Memory difficulties *

None
Mild
Moderate
Severe
Very severe

Low sex drive *

None
Mild
Moderate
Severe
Very severe

Night sweats *

None
Mild
Moderate
Severe
Very severe

Hair changes / thinning *

None
Mild
Moderate
Severe
Very severe

Brittle nails *

None
Mild
Moderate
Severe
Very severe

Dry skin / loss of skin tone *

None
Mild
Moderate
Severe
Very severe

Excess weight or difficulty losing weight, especially around the waist *

None
Mild
Moderate
Severe
Very severe

Feeling cold all the time *

None
Mild
Moderate
Severe
Very severe

Difficulty building or maintaining muscle *

None
Mild
Moderate
Severe
Very severe

Bladder problems / incontinence *

None
Mild
Moderate
Severe
Very severe

Discomfort with intercourse / vaginal dryness *

None
Mild
Moderate
Severe
Very severe

Hot flashes *

None
Mild
Moderate
Severe
Very severe

Note: the above symptoms are typical of hormonal imbalances, which are increasingly common as we age. Hormonal imbalances can not only deprive you of your quality of life and vitality, but can also increase your risk for coronary artery disease, cerebrovascular disease, osteoporosis, cognitive decline, insulin resistance, and diabetes. It can also lead to genitourinary symptoms such as incontinence, vaginal dryness and atrophy, and discomfort with intercourse.

Symptom Questionnaire for Men

Sleep problems. *

None
Mild
Moderate
Severe
Very severe

Anxiety. *

None
Mild
Moderate
Severe
Very severe

Physical exhaustion / fatigue. *

None
Mild
Moderate
Severe
Very severe

Decline in drive or motivation. *

None
Mild
Moderate
Severe
Very severe

Joint and muscular symptoms (aches and pains). *

None
Mild
Moderate
Severe
Very severe

Memory difficulties. *

None
Mild
Moderate
Severe
Very severe

Low sex drive. *

None
Mild
Moderate
Severe
Very severe

Night sweats. *

None
Mild
Moderate
Severe
Very severe

Hair changes / thinning. *

None
Mild
Moderate
Severe
Very severe

Brittle nails. *

None
Mild
Moderate
Severe
Very severe

Dry skin / loss of skin tone. *

None
Mild
Moderate
Severe
Very severe

Feeling cold all the time. *

None
Mild
Moderate
Severe
Very severe

Bladder problems / incontinence. *

None
Mild
Moderate
Severe
Very severe

Difficulty building or maintaining muscle. *

None
Mild
Moderate
Severe
Very severe

Excess weight or difficulty losing weight, especially around the waist. *

None
Mild
Moderate
Severe
Very severe

Difficulty achieving or maintaining an erection. *

None
Mild
Moderate
Severe
Very severe

Many of the above symptoms are typical of hormonal imbalances which are increasingly common as we age. Hormonal imbalances can not only deprive you of your quality of life and vitality, but can also increase your risk for coronary artery disease, cerebrovascular disease, osteoporosis, cognitive decline, insulin resistance, and diabetes.

Treatment Cost Statement

Dr. Crisci, in addition to her 20 years of clinical experience, has been formally trained in bioidentical hormone replacement therapies by a variety of prestigious associations such as the Menopause Society, the American Academy of Anti-Aging Medicine (A4M) and others. She offers a comprehensive, evidence-based approach to hormone optimization to set you on the best possible trajectory as you age.

Despite holding an unrestricted license by the College of Physicians and Surgeons of BC, BHRT is considered ‘Complementary and Alternative Medicine’ which means that the clinical care and associated investigations (testing) are not covered by the Medical Services Plan of BC (your health card).

The pricing for this treatment for the first 12 months is $2999.00 + GST CAD, which includes an initial personalized 45 minute consultation with Dr. Crisci and all medical visits (in person for via phone/video), all prescription refill requests, all laboratory administration fees for Lifelabs testing of main sex (gonadal) hormones, and 15% off pelleting procedures if chosen. All BHRT clients also receive a significant discount on our aesthetic services, supplements, and other services.

Our payment plan is offered to all clients. Pay $1499 for your initiation fee, and $125 per month for 12 months. Subsequent years do not have an initiation fee, and your monthly cost drops to $79 per month. All prices are subject to GST.

Insurance coverage statement *

I understand that BHRT constitutes a type of care that is considered complementary and alternative, and that I am responsible for payment. It is also my responsibility to verify ahead of time with my private insurance if this type of care is covered.

The purpose of this questionnaire is to ensure that you are a good candidate for Dr. Crisci’s practice. Please answer the following questions as accurately as possible:

Do you currently have, or have you had in the past, any of the following: *

Breast cancer
Skin Cancer
Cancer, other
Blood clot (e.g. in legs or lungs)
Blood or clotting disorder such as polycythemia vera, factor V leiden deficiency or hemochromatosis
TIA / stroke
Heart attack / angina
None of the above

Has a healthcare provider ever told you that hormones were not recommended in your situation? *

Are you currently followed by a specialist for a medical issue? If yes, please describe below. *

Are you currently pregnant, thinking of possibly getting pregnant, trying to conceive or breastfeeding? *

If you are of childbearing age, what is your method of contraception? *

The purpose of this questionnaire is to ensure that you are a good candidate for Dr. Crisci’s practice. Please answer the following questions as accurately as possible:

Do you currently have, or have you had in the past, any of the following:

Prostate cancer
Skin Cancer
Cancer, other
Blood clot (e.g. in legs or lungs)
Blood or clotting disorder such as polycythemia vera, factor V leiden deficiency or hemochromatosis
TIA / stroke
Heart attack / angina
None of the above

Has a healthcare provider ever told you that hormones were not recommended in your situation? *

Are you currently followed by a specialist for a medical issue? If so, please give details. *

Are you currently trying to conceive? *

We encourage all our prospective patients to explore our FAQs here on our website and to watch the recording of one of Dr. Crisci's live webinars, to ensure that they are aware of her credentials as a medical doctor, her expertise, her clinical approach, and her care philosophy prior to deciding to join her practice.

Due to high demand for Dr. Crisci’s services, we are currently booking appointments based on client readiness and availability. Please select the option that best describes your situation: *

1: I am ready to begin my personalized treatment plan now. I wish to proceed to payment of my initiation fee, and begin my treatment at the first available appointment. (Typically 3-5 weeks.) I would like to be contacted to book my initial consultation, and will receive my first lab requisition, which I will take to Lifelabs at least one week prior to my appointment.
2: I have some questions or concerns that I would like to discuss with Dr. Crisci in a short 15 min. video consultation before making a decision. I understand this will delay the start of my treatment by weeks or months. (Please note that due to demand for these discovery calls, there may be a wait time of 6 months or more.)
3: I need more time to consider my options, and am not ready to make a decision at this time. I will reach out when I have reached a decision.

Are you ready to submit your profile?

I hereby confirm that the information provided in this medical questionnaire is accurate and complete to the best of my knowledge. I understand that withholding any relevant information about my current or past medical history may affect my eligibility to become Dr. Crisci’s patient. Please use the “previous” button to review and change any sections before submitting.

Comment

Symptom Questionnaire for Women

Symptom Questionnaire for Men

Treatment Cost Statement

The purpose of this questionnaire is to ensure that you are a good candidate for Dr. Crisci’s practice. Please answer the following questions as accurately as possible:

The purpose of this questionnaire is to ensure that you are a good candidate for Dr. Crisci’s practice. Please answer the following questions as accurately as possible:

Are you ready to submit your profile?

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