Her Hormone Club Initial Evaluation - General, BYOT and Thyroid

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HE- Unique ID
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Full Name* This field is required.
First Name
Last Name
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E-mail* This field is required.
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Phone Number* This field is required.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
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Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
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Australia
Austria
Azerbaijan
The Bahamas
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The Gambia
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Samoa
San Marino
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Saudi Arabia
Senegal
Serbia
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Singapore
Slovakia
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Somalia
Somaliland
South Africa
South Ossetia
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Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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How Did You Hear About Us?* This field is required.
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Are You A Resident of The United States of America?* This field is required.We are not able to provide services to residents outside the United States. If you are not a United States resident you will be directed to a page stating you are not a fit for the program and should contact us for a refund as we are not able to service you.
YESNO
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State of Residence* This field is required.We are not able to provide services to residents of NY, NJ, RI or outside the United States. If any of these is entered you will be directed to a page stating you are not a fit for the program and should contact us for a refund as we are not able to service you.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Maine
Maryland
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Her Hormone Club Essentials Program Cost Confirmation* This field is required. Please confirm that you are applying for the Her Hormone Club Essentials Program with an initial payment of $1497 today and continuing monthly payments from $127 to $327 per month depending on number of hormones needed monthly. You must submit payment at the end of this application or your application will not be complete.This program provides up to 5 hormones for daily use, testing at least twice yearly and more frequently if thyroid is needed, physician consultations after each test.
YESNO
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What is your age?* This field is required.
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Date of Birth* This field is required.
Date
Month
Day
Year
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Check all which you would like to be considered for:* This field is required.
Continous Glucose Monitor
Natural Thyroid Medication Treatment
Bioidentical Hormone Replacement Therapy
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Are you in menopause already? * This field is required.You are in Menopause if you've had no period for 12 months or you've had a hysterectomy and your ovaries were removed or your ovaries were removed or a blood test said you were in menopause. No period because you had an ablation does not mean you are in menopause.
YESNO
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What do you do to prevent pregnancy?List birth control method in current use such as vasectomy, tubal ligation, IUD, OCP, Implants, Nuvaring, diaphragm, cervical cap, Essure or not at risk due to same sex partner. Endometrial ablation is not a method of pregnancy prevention.
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Ok
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Do you have any personal history of breast or uterine cancer or abnormal mammogram or uterine imaging within the past five years?* This field is required.
YESNO
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Please give details, including dates, procedures, findings, final outcomes and follow up required.
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Ok
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Have you had a mastectomy?
YESNO
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What type of alternate mammogram screenings do you get annually (ex: MRI, Ultrasound or specialized physician exam)
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Ok
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When did you last have an alternate mammogram screening?
Date
Year
Month
Day
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Do you have a personal history of having elevated liver enzymes on blood work or a liver disorder in the past five years?* This field is required.
YESNO
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Please give details, including dates, procedures, findings, final outcome and follow up required.
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Do you have any personal history of a blood clotting or vascular disorder such as Factor V Leiden, DVT (Deep Vein Thrombosis), Pulmonary Embolus, Stroke, Heart Attack, Coronary Artery Disease or other hypercoagulable blood or vascular state?* This field is required.
YESNO
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Please give details, including dates, procedures, findings, final outcome and follow up required.
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Ok
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Do you have a personal history of uterine fibroids, endometriosis OR abnormal vaginal bleeding that has not been evaluated by your personal physician in the past five years?* This field is required.
YESNO
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Please give detail, including dates, procedures, findings, final outcome and follow up required.
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Ok
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Have you ever had an adverse reaction to any hormonal medication such as birth control pills or hormone replacement therapy?* This field is required.
YESNO
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Please give detail, including dates, procedures, findings, final outcome and follow up required.
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Ok
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Are you currently using any hormonal therapy including estrogen, progesterone, testosterone, birth control pills, Mirena, depo provera, implants or other hormonal agents?* This field is required.
YESNO
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Please detail the specific medications* This field is required.
Medication Name
Dose
Route of Administration
Dosing Interval
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Do you have a personal history of elevated triglycerides requiring medication treatment?* This field is required.
YESNO
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Please give detail, including dates, procedures, findings, final outcome and follow up required and indicate if you have an inherited triglyceride disorder.
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Do you agree to maintain a relationship with your primary care physician during the course of your hormone treatment with visits at least annually?* This field is required.
YESNO
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Do you agree to undergo mammographic or alternative breast screening (MRI, ultrasound, etc.) every 2 years from the age of 40 to 50 and annually from the age of 50 on while on hormone therapy?* This field is required.
YESNO
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What hormonal symptoms are you interested in alleviating?* This field is required.Please detail your symptoms here.
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Please check all symptoms which apply to you CURRENTLY (Not Past) :* This field is required.
Irregular or heavy menstrual cycles and PMS symptoms
Fibroids, endometriosis, ovarian cysts, PCOS (polycystic ovarian syndrome)
Infertility
Fibrocystic breasts
Breast or uterine cancer within the past 5 years
Menopause
Hot flashes or night sweats
Decreased sex drive or enjoyment
Vaginal dryness
Difficulty falling or staying asleep
Daytime sleepiness or fatigue
Headaches
Anxiety, irritability, moodiness or depression
Concentration or memory problems
Loss of muscle mass
Acne
Facial or excess body hair
Hair loss
Weight gain or loss
Less than one BM daily
Loose or unformed stools
Palpitations
Bulging eyes
Dry skin or hair
Cold hands or feet
Cold intolerance
Profuse sweating
Thyroid disorder
Seasonal allergies or sinusitis
Asthma or other respiratory disease
Frequent infections or illnesses
Autoimmune disease
Inflammatory disease
Arthritis
ADD/ADHD
None
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Number of Pregnancies* This field is required.
0
1
2
3
4
5
6
7
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Number of Live Births* This field is required.
0
1
2
3
4
5
6
7
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Date of Last Menstrual Period* This field is required.If menopausal, put year of last menstrual period
Date
Year
Month
Day
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Have you had a hysterectomy?* This field is required.
YESNO
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Provide date of hysterectomy:
Date
Year
Month
Day
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Provide type of hysterectomy and indicate if ovaries were removed or not:
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Please check all of the following which you have had. If none, please check none.* This field is required.
Fibrocystic Breasts
Breast Cancer
Uterine Fibroids
Endometriosis
Uterine Cancer
Cervical Cancer
Unexplained Vaginal Bleeding
None
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Date of last mammogram:* This field is required.The Hormone Club membership requires that you have a mammogram every other year from 40-50 years of age and annually thereafter. It's ok if your last mammogram was longer than 1-2 years ago as long as you agree to have one completed before your physician consultation.
Date
Year
Month
Day
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Date of last complete physical exam:* This field is required.
Date
Year
Month
Day
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Name, address and phone number of physician who performed examination:* This field is required.
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Have you had an abnormal mammogram?* This field is required.
YESNO
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Please provide details of abnormal mammogram:
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Ok
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Have you taken hormone replacement therapy before or currently?* This field is required.
YESNO
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Please provide details:
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What is your most recent weight in pounds (lb)?* This field is required.
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What is your height in inches?* This field is required.
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Was your most recent blood pressure reading normal?* This field is required.
YESNO
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Please provide details
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Please check all of the following which you have had. If none, please check none.* This field is required.
Hypertension
High Cholesterol
Diabetes
Thyroid Disease
Autoimmune Disease
Adrenal Dysfunction
Blood Clots
Stroke
TIA
Heart Disease or Attack
Liver Disease
Kidney Disease
Porphyria
Clotting Problems
Thrombophilia
Active Gallbladder Disease
None
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Please list any current medications you're taking:* This field is required.
Medication Name
Dose
Route of Administration
Dosing Interval
#1
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#2
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Please list any current supplements you're taking:* This field is required.
Supplement Name
Dose
Route of Administration
Dosing Interval
#1
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#2
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Please list any allergies you have:* This field is required.
Allergy
Type
Severity
Reactions
#1
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#2
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Are there any of the following medical conditions in your family history that you are aware of? Please tick all that apply.* This field is required.
Heart Disease or Attack
Stroke
TIA
Clotting Disorder
Bleeding Disorder
Breast or Uterine Cancer
Liver Disease
Kidney Disease
None
59
Do you smoke tobacco?* This field is required.
YESNO
60
How many packs per day for how many years?
61
Do you consume alcohol?* This field is required.
YESNO
62
How many drinks per week do you consume?
63
Testing and Monitoring Only: Have you been told by a provider recently that you do not yet need a prescription for hormone therapy and/or are not a candidate for a thyroid hormone prescription and you are ONLY wanting regular testing of your hormones twice yearly with a follow up consultation with our physicians until you need hormones?
YESNO
64
Do you have your own test results, obtained within the past three months, to upload for the Bring Your Own Test Program
YESNO
65
Upload Your Test Results
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
66
Have you ever completed a DUTCH test?* This field is required.
YESNO
67
Date most recent DUTCH test was completed:
Date
Year
Month
Day
68
Type of DUTCH Test
DUTCH Sex Hormone
DUTCH PLUS
69
Please upload your most recent DUTCH test results:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
70
Have you completed a thyroid bloodwork panel?* This field is required.
YESNO
71
Date most recent thyroid panel completed:
Date
Year
Month
Day
72
Please upload your most recent thyroid panel results:
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
73
Are you ONLY wanting treatment for your thyroid and NOT your sex hormones?
YESNO
74
Terms & Conditions Patient Agreement* This field is required.Her Hormone Club PC (Updated Sept 2023)
75
Terms & Conditions Patient Signature* This field is required.BY SIGNING BELOW, Patient (OR, IF Patient IS A MINOR, PATIENT’S PARENT OR LEGAL GUARDIAN) HAS READ OR REVIEWED THIS AGREEMENT AND KNOWINGLY, FREELY AND WILLINGLY AGREES TO BE BOUND BY ITS TERMS AND THE TERMS OF PATIENTSHIP. IT IS ACKNOWLEDGED THAT NO PROMISES HAVE BEEN MADE TO PATIENT BY COMPANY RELATING TO ANY OUTCOME OR RESULT OF PATIENT SERVICES.
76
Missed Appointment Policy Patient Signature* This field is required.BY SIGNING BELOW, Patient (OR, IF Patient IS A MINOR, PATIENT’S PARENT OR LEGAL GUARDIAN) AFFIRMS THAT THEY ARE AWARE OF THE MISSED APPOINTMENT POLICY STATING THAT A $150 FEE WILL BE CHARGED TO THE FORM OF PAYMENT ON FILE IF THEY FAIL TO ATTEND A SCHEDULED APPOINTMENT REGARDLESS OF THE REASON FOR SUCH FAILURE. INVALID REASONS FOR MISSING AN APPOINTMENT INCLUDE LACK OF WIFI ACCESS, LACK OF AUDIO AND VIDEO TELECONFERENCING ACCESS, CONFUSION OVER TIME ZONES AND ALL OTHERS. YOUR SIGNATURE BELOW AFFIRMS YOUR AGREEMENT WITH THIS MISSED APPOINTMENT POLICY.
77
Cancellation Policy Patient Signature* This field is required.BY SIGNING BELOW, Patient (OR, IF Patient IS A MINOR, PATIENT’S PARENT OR LEGAL GUARDIAN) AFFIRMS THAT THEY ARE AWARE OF THE CANCELLATION POLICY Cancellation Notice: To cancel your membership, you must provide written notice to Her Hormone Club PC by email to hello@herhormoneclub.com at least 30 days prior to your desired cancellation date. The notification must explicitly state to "cancel my membership with Her Hormone Club PC". Failure to provide such notice will result in the automatic renewal of your membership for an additional billing cycle. Final Payment: Upon receiving your cancellation notice, Her Hormone Club PC will charge your payment method on file for one final billing cycle, regardless of the remaining days in that cycle. This final payment is non-refundable and represents the agreed-upon early termination fee. Acknowledgment: By signing this agreement, you acknowledge and agree to the cancellation terms outlined above, including the requirement to provide 30 days' notice and the payment of a final, non-refundable billing cycle as an early termination fee.
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