BHRT Hormone Evaluation and Medical History (HRT Form #3)

HORMONE EVALUATION AND MEDICAL HISTORY

This information will be reviewed by our certified hormone specialist in order to provide a custom-tailored prescription to fit your needs. Thank you for taking the time to complete this comprehensive questionnaire!
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your Gender?*

MaleFemale
Height (in inches)*
Weight (in pounds)*
Do you use tobacco?*

YesNo
How Often and how much?*
Do you consume alcohol?*

YesNo
How Often and how much?*
Do you consume caffeine?*

YesNo
How Often and how much?*
Provider Name

First NameLast Name
Provider Phone Number
Please enter a valid phone number.
Allergies - Please check all that apply:*

No known drug allergiesMorphinePenicillinCodeineSulfaAspirinFood AllergiesDye AllergiesNitrate AllergiesPet AllergiesSeasonal Allergies
Please describe the allergic reaction you experienced when it occurred?
Current Prescription Medications (Name / Strength / Date Started / How Often Per Day)
Over-the-counter (OTC) Medications: Please check all products that you use occasionally or regularly. Check all that apply.

Pain RelieverAntihistamine Product (ex: benadryl)AspirinCombination Product (cough + cold reliever)Acetaminophen (ex: Tylenol)Sleep aids (ex: Unisom)Ibuprofen (ex: Motrin)Antidiarrheals (ex: Imodium)Naproxen (ex: Aleve)Laxatives/stool softenersKetoprofenDiet aids/weight loss productsCough Suppressant (ex: Robitussin DM)Antacids (ex: Maalox)Acid Blockers (rx: Pepcid)Decongestants (ex: Sudafed)Other
Nutritional/Natural Supplements: Please check all products that you use occasionally or regularly. Check all that apply:

Vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene)Minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals)Herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.)Enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)Nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.)Other
Please List the nutritional/natural supplement products that you take:
Medical Conditions/Diseases: Please check all that apply to you.

Heart disease (example: Congestive Heart Failure)High cholesterol or lipids (examples: Hyperlipidemia)High blood pressure (example: Hypertension)CancerUlcers (stomach, esophagus)Thyroid diseaseHormonal Related IssuesLung condition (example: asthma, emphysema, COPD)Blood Clotting ProblemsDiabetesArthritis or joint problemsDepressionEpilepsyHeadaches/migrainesEye Disease (glaucoma, etc.)Other
Please List Hormones Previously Taken (Date Started / Date Stopped / ReasON0:
Bone Size*

SmallMediumLarge
Body Type*

Androgenic (narrow hips, fat carried in abdomen, etc.)Estrogenic (broader hips, fat carried in hips, thighs, buttocks, etc.)
Have you ever used Oral Contraceptives?*

YesNo
Any Problems Taking Oral Contraceptives?

YesNo
Please describe the problem:*

Pregnancy History

	Yes / No	Date
How many pregnancies have you had?
How many children?
Any interrupted pregnancies?
Have you had a hysterectomy?
Ovaries removed?
Have you had a tubal ligation?

Do you have a family history of the following?

	No	Yes	Family Member(s)
Uterine Cancer
Ovarian Cancer
Breast Cancer
Heart Disease
Osteoporosis

Have you had any of the following tests performed?

	No	Yes	Date
Mammography
PAP Smear
Breast Cancer
Heart Disease
Osteoporosis

Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles?*

YesNo
Please explain (such as age when this occurred, symptoms….)
When was your last period?
How many days did it last?
Do you have, or did you ever have Premenstrual Syndrome (PMS)?*

YesNo
What type of birth control do you use?
Please explain symptoms:
How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?*

Doctor/ProviderSelfFriend/Family MemberOther
What are your goals with taking BHRT?*
Please write down any questions you have about Bio-Identical Hormone Replacement Therapy.*
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HORMONE EVALUATION AND MEDICAL HISTORY