Women's BHRT Evaluation Form
A detailed medical history and thorough symptom evaluation are critical components of developing a plan to meet your health goals concerning bio-identical hormone replacement therapy. Here at Hawthorne, we believe in treating each patient as a whole, not an individual symptom or lab value. So, we ask that you answer the following questions as accurately and thoroughly as possible so that we can better serve your needs. **This form is HIPAA compliant. All information provided will be treated as protected health information and will be kept confidential under Hawthorne Pharmacy's Privacy Practices https://www.hawthornesc.com/sites/default/files/documents/NoticePrivacy.pdf After you complete this evaluation and submit your saliva test kit for processing (if applicable), you may schedule a consultation via our website. You may also contact the compounding lab at 803.227.4452 for help with scheduling or if you have any questions throughout this process. Consultations cost $75.00 and are HSA-eligible. Consultations are not billable to insurance.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
 -
Month
 -
Day
Year
Date
Email
*
example@example.com
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Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
What's the best way to contact you?
*
Email
Home phone
Work phone
Mobile phone
Text message
Occupation
*
Marital Status
*
Please Select
Married
Single
Widowed
Divorced
Hours Worked
Full Time
Part Time
Retired
How did you hear about bio-identical hormone replacement therapy?
Do you understand what bio-identical hormone replacement therapy (BHRT) is?
What are your goals for BHRT?
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Medical Status
Age
Height
Weight
General health:
Excellent
Good
Fair
Poor
Current Medical Conditions:
Drug Allergies:
Environmental/Food Allergies:
Current Medications:
Current Vitamins/Over-the-Counter Products:
Current Herbs:
Have you ever had your cholesterol level checked?
Yes
No
What was the date?
What was the result?
Have you ever had a mammogram?
Yes
No
What was the date?
What was the result?
Have you ever had a bone density scan?
Yes
No
What was the date?
What was the result?
Have you ever had your hormone levels tested?
Yes
No
What was the date?
What was the result?
Who is your current physician?
What is your current physician's phone number?
*
Do you have prescription insurance?
Yes
No
Insurance Company
Insurance ID#
Group #
BIN #
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Past Medical Conditions
Childhood Diseases:
Please check all that apply to you:
Heart trouble
Diabetes
Fractures
Asthma
Chronic fatigue
High blood pressure
Clotting defects
Arthritis
Cancer
Stroke
Kidney trouble
Colitis
Fibromyalgia
Varicose veins
Epilepsy
Gallbladder trouble
Eating disorder
Habits
Dietary restrictions:
Do you do routine physical exercise?
Yes
No
What type?
Do you currently use tobacco products?
Yes
No
How much?
If you previously used tobacco products, how much did you use?
Do you currently use alcohol products?
Yes
No
How much?
If you previously used alcohol products, how much did you use?
Do you currently use caffeine products?
Yes
No
How much?
If you previously used caffeine products, how much did you use?
Do you use artificial sweeteners?
Yes
No
How much?
What kind?
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Family History
Please list family members who are still living, with their age and any important diseases such as: high blood pressure, heart disease, cancer, diabetes, osteoporosis, etc.
Please list family members who died of important diseases (see examples above) and their age at the time of death.
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Gynecological History
Age at first period:
Date of last period:
Date of last pelvic exam:
Results of last pelvic exam:
Date of last pap smear:
Results of last pap smear:
Have you ever had an abnormal pap?
Yes
No
When?
Are you sexually active?
Yes
No
Are you trying to get pregnant?
Yes
No
How many days from the start of one period to the next?
How many days of flow?
Days amount of bleeding?
Days amount of cramps?
Days amount of premenstrual symptoms?
Any bleeding between periods?
Yes
No
If yes, when?
Age at first pregnancy
How many full term pregnancies?
Any problems during your pregnancies?
Any interrupted pregnancies (miscarriages or abortions)?
Have you had a tubal ligation?
Yes
No
When?
Have you had a hysterectomy?
Yes
No
When?
Have your ovaries been removed?
Yes
No
What methods of birth control do you use? Select all that apply.
Birth control pills
Partner vasectomy
Hysterectomy
Other
If you selected other, what treatment?
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Past/Current Hormone Replacement Therapy
Please list any hormone replacements you have taken (ex. Androgel, Testim, Testoterone, DHEA, HCG, etc). List the medication, date taken, problems or reasons for stopping.
Symptoms
Please rate your current status for each symptom below:
Rows
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
Acne
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
Any additional comments:
Submit
Should be Empty: