Patient Information
Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Height
*
Weight
*
Desired Weight
*
Do you use tobacco?
*
Yes
No
How often and how much?
Do you use alcohol?
*
Yes
No
How often and how much?
Do you use caffeine?
*
Yes
No
How often and how much?
Do you exercise?
*
Yes
No
How often and how much?
Please list any DRUG allergies and describe the reaction that occurs:
*
Please list any FOOD allergies and describe the reaction that occurs:
*
Please list any OTHER allergies and describe the reaction that occurs:
*
Over-the-counter medication history: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):
*
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc).
*
Current prescription medications, including hormones (please list medication name and strength, date started, and how often per day):
*
List hormones previously taken (please list medication name and strength, date started, and how often per day):
*
Have you ever used oral contraceptives (birth control)?
*
Yes
No
If you experienced any problems, please describe:
*
How many pregnancies have you had?
*
How many children?
*
Any interrupted pregnancies?
*
Yes
No
If yes, please explain:
*
Have you had a tubal ligation?
*
Yes
No
If yes, date of surgery:
*
-
Month
-
Day
Year
Date
Have you had a hysterectomy?
*
Yes
No
If yes, date of surgery:
-
Month
-
Day
Year
Date
Reason for surgery:
Do your ovaries remain?
*
Yes
No
Do you have a family history of any cancers or osteoporosis? Please list the family member(s):
*
Have you had a Mammography test performed?
*
Yes
No
Date
-
Month
-
Day
Year
Date
Outcome of Mammography Test:
Have you had a PAP Smear test performed?
*
Yes
No
Date
-
Month
-
Day
Year
Date
Outcome of PAP Smear Test:
Have you had a Bone Density test performed?
*
Yes
No
Date
-
Month
-
Day
Year
Date
Outcome of Bone Density Test:
What age did your period start?
*
How many days is/was your cycle? (Example: 28)
*
Is/was your menstrual flow heavy or light?
*
Any clots?
*
Yes
No
Have you ever had what YOU would consider to be abnormal cycles?
*
Yes
No
If yes, please explain:
When was your last period?
*
-
Month
-
Day
Year
Date
How many days did it last?
*
Do you have or have ever suffered from Premenstrual Syndrome (PMS) symptoms?
*
Yes
No
If yes, please explain:
Please choose which best describes your symptoms.
*
Rows
Absent
Mild
Moderate
Severe
Hot Flashes
Night Sweats
Vaginal Dryness
Incontinence
Bleeding Changes
Fibrocystic Breast
Weight Gain
Fluid Retention
Dry Skin/Hair
Hair Loss
Anxiety
Depression
Mood Swings
Irritability
Headaches
Breast Tenderness
Cramps
Difficulty Falling Asleep
Difficulty Staying Asleep
Fatigue
Loss of Memory
Foggy Thinking
Acne
Arthritis
Decreased Sex Drive
Harder to Reach Climax
Stress
Other symptoms:
What are your goals for taking Hormone Replacement Therapy?
*
Doctor that we should contact for this therapy:
*
Have you currently discussed hormone replacement therapy with your provider? Are the open to prescribing it to you if appropiate?
*
Doctor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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