At Replenish Wellness Center, our goal is to understand the response pattern you are having while on your personalized Treatment Protocol. Whether you have come to Replenish Wellness Center for Traumatic Brain Injury (TBI), Low Testosterone Syndrome, Estrogen Dominance, Menopause, or for Post-Finasteride Syndrome, this information will help when we are between blood tests.
Below, please click for a short 25 questions Monthly Progress Questionnaire (MPQ) that I would appreciate you filling out every 30 days during the first year, and then quarterly or semi-annually thereafter. The information you provide might support the modification of your initial or on-going Treatment Protocol in a more timely manner than waiting 3 - 6 months for a laboratory test to tell us exactly what you were feeling. I will respond to your Monthly Progress Questionnaire (MPQ) once received in my office.
This form is fillable on screen. After completion, SAVE the form and Email to SandraT@ReplenishWellnessCenter.com. It does not need to be printed out. Once you fill it out, save it to your computer hard drive naming it something such as MPQ2021.09 (for the year 2021 and the 9th month). You may also save the “Sent” email where you can find each one. This way you can watch your own progression on your Treatment Protocol.
I suggest that you place a reminder in your Task Manager or Calendar so we do not miss these.
Email your MPQ to SandraT@ReplenishWellnessCenter.com. If you would like, you may print this form, complete it, and fax to 256-885-1905.
Thank you again for your participation in your own health.
All the best,
James D. Thacker, MD
Replenish Wellness Center
Millennium – TBI Network Member
1. Download the MPQ Form
2. Fill in your Name (First & Last) and the Date you are filling out the MPQ
3. Most Important – Your choice of a number score is based upon prior to Treatment to the date you fill out the MPQ. It is NOT from the last time you filled out the MPQ – but always from the pre-treatment period to the present
4. The Range is from Zero to Ten
(0 – 10)
5. Please check “N/A” if the question does not apply
6. Save and Email the MPQ