Pelledoser - Pellecome

New or Returning Patient

Patient Information

Age

Weight (lbs)

Returning Patient Questions

Are hormone related symptoms well controlled?

If not, do the symptoms persist or are excess symptoms noted?

Female Patient Question

Pre-perimenopausal

Patients who still having periods regularly or occasionally

Postmenopausal

Patients without menstrual periods for 6-12 months

Blood Test Results

Systolic Blood Pressure

FSH

Testosterone, Total

Cholesterol, Total

Cholesterol, HDL

CRP, Cardio

DHEA

Hgb A1C

TSH

Vitamin D

Cortisol

Treatment for :

Hypertension

Diabetes

Smoking

Current Dose

Current Estradiol Dose

Current Testosterone Dose

Female Patients Risk Factors

Acne/Facial Hair

Hair Loss

Hysterectomy

PCOS

Heavy Menses

Metabolic Syndrome

Breast Pain

Mid-Cycle Bleeding

Headache

Fluid Retention

Fibrocystic Breast Disease

Increase Breast Density

Hair Growth

BMI > 30

History of Aggressive Behavior

History of Stroke or Heart Attack

Male Patients Risk Factors

Benign Prostatic Hyperplasia

Prostate Cancer History

Congestive Heart Failure

Erythrocytosis (HTC > 50)

Breast Cancer

Concern about Infertility

Physical Activity (High/Low)

Female BHRT Doses

Estradiol

n/a

Testosterone

n/a

Progesterone*

n/a

Note: The Re3® PelleDoser does not calculate Progesterone needs, however it is recommended that women receive 100 mgs Progesterone in pellet form for the insertion and also are prescribed 100-200 mgs to be taken orally on a daily basis. If no pellet is inserted, then it is recommend 200 mgs be prescribed orally on a daily basis.

Female Booster Doses

Estradiol

n/a

Testosterone

n/a

Progesterone

n/a

Male BHRT Doses

Testosterone

n/a

Male Booster Doses

Testosterone

n/a

Recommended pellecomeFIT® Supplements

Based on the inputted Blood Test Results, the following are recommended:

- DIM

- Pregnenolone

- Stress Energizing

Print Results

New or Returning Patient

Patient Information

Returning Patient Questions

Are hormone related symptoms well controlled?

If not, do the symptoms persist or are excess symptoms noted?

Female Patient Question

Pre-perimenopausal

Patients who still having periods regularly or occasionally

Postmenopausal

Patients without menstrual periods for 6-12 months

Blood Test Results

Treatment for :

Hypertension

Diabetes

Smoking

Current Dose

Female Patients Risk Factors

Acne/Facial Hair

Hair Loss

Hysterectomy

PCOS

Heavy Menses

Metabolic Syndrome

Breast Pain

Mid-Cycle Bleeding

Headache

Fluid Retention

Fibrocystic Breast Disease

Increase Breast Density

Hair Growth

BMI > 30

History of Aggressive Behavior

History of Stroke or Heart Attack

Male Patients Risk Factors

Benign Prostatic Hyperplasia

Prostate Cancer History

Congestive Heart Failure

Erythrocytosis (HTC > 50)

Breast Cancer

Concern about Infertility

Physical Activity (High/Low)

Female BHRT Doses

Estradiol

Testosterone

Progesterone*

Female Booster Doses

Estradiol

Testosterone

Progesterone

Male BHRT Doses

Testosterone

Male Booster Doses

Testosterone

Recommended pellecomeFIT® Supplements

- CardioFit

- L-Glutathione

- DHEA

- GlucoFit

- GlucoFit and it is recommended that you consult with a doctor re: your high A1C levels

- Power T Booster

- ThyroFit

- Vitamin D3 & K2 Liquid Drops

- DIM

- Pregnenolone

- Stress Energizing

QUICK LINKS

OFFICE

Pellecome LLC 240 Main Street Bldg A; Suite #1 Gladstone, NJ 07934

888.773.9969

info@pellecome.com

Pellecome LLC
240 Main Street
Bldg A; Suite #1
Gladstone, NJ 07934