Women's BHRT Follow-Up Form

Women's BHRT Follow-Up Form

Follow-ups are crucial to positive patient progress with hormone replacement. All information provided below will be kept confidential. After you fill out this evaluation a pharmacy representative with contact you to set up a consultation time with one of our pharmacist consultants at our Taylor Street location. Follow-up consultations can be done over the phone if requested. There is a charge for follow-up consultation based on time allowed.
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
What's the best way to contact you?*

EmailHome phoneWork phoneMobile phoneText message
Rx Number
How long have you been on Bio-Identical Hormone Replacement Therapy?

	Absent	Mild	Moderate	Severe
Hot flashes
Night sweats
Headaches
Difficulty falling asleep
Difficulty staying asleep
Breast tenderness
Irritability
Depression
Weight gain
Low libido
Fuzzy thinking
Bloating
Anxiety
Mood swings
Vaginal dryness
Fatigue
Hair loss
Constipation
Salt cravings
Sugar cravings
Painful intercourse
Fertility issues
Joint aches and pains
Increased facial or body hair
Dry/brittle hair or nails
Cold body temperature
Unusual sweating
Bulging eyes
Blood pressure problems
Hoarseness
Dry eyes
Dry skin
Oily skin

Symptoms