HRT Consultation Form

Uptown Pharmacy Hormone Consultation

Patient Information
Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient E-Mail*
example@example.com
Phone Number
Please enter a valid phone number.
Patient Gender*
Patient Birth Date*

MonthDayYear
What prescriber referred you to Uptown Pharmacy for consultation?
Have you had lab work done to measure your hormones?
Patient Medical History
Please list any drug and non-medication allergies and the reactions you experienced.
Have you ever had (Please check all that apply)

AnemiaCancerDiabetesHeart Disease / High Blood PressureHeart AttackThyroid Problems
Other conditions:
Have you tried hormone replacement previously? If so, please indicate the dose and the results of your prior hormone replacement therapy.
Please list your Current Medications and supplements with their respective strengths and how you take them.
example: Lipitor 20mg every night
What is your greatest need or problem? (List the most important, then list other issues in order of importance.)
Have you ever had a bone density scan?

Yes, within the past yearYes, more than a year agoNo, I have not had a bone density scan
Do you use tobacco products

Yes, one or more packs per dayYes, one or more packs per weekYes, one or more packs per monthNo, I do not use tobacco products
Alcohol Consumption

I don't drinkless than once a month1 or more times per month1 or more times per week1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeineOne or more times per monthOne or more times per week1-2 cups/day3-4 cups/day5+ cups/day
Do you use recreational drugs?

NoYes
When was your last general medical exam

Less than 1 month agoLess than 6 months agoLess than 1 year agoI have not had a recent general medical exam
When was your last pelvic exam

Less than 1 month agoLess than 6 months agoLess than 1 year agoI have not had a recent general medical exam
Have you ever had an abnormal pap smear?

YesNo
Please indicate the approximate date of the abnormal pap smear as well as the treatment you received because of the abnormal pap smear.
Date (approximate) of your last menstrual period.

MonthDayYear
Date
Have you experienced difficult, irregular, or abnormal periods?

YesNo
Please describe.
Have you ever had Premenstrual Symptoms (PMS)?

YesNoI am not sure
Please describe.
Have you experienced any recent unusual vaginal discharge or itching?

YesNo
Have you had a tubal ligation (tubes tied)?

YesNo
Have you had a hysterectomy (uterus removal)?

YesNo
Have you had an oophorectomy (ovary removal)?

YesNo
Have your physician diagnosed menopause, or told you that you are in menopause?

Yes, within the past monthYes, within the past six monthsYes, within the past yearYes, more than one year agoNo
Have you ever been pregnant?

YesNo
For the following symptoms, please rate their impact on your daily life
Hot flashes / flushes

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Night Sweats

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Light-headed feelings/ Dizziness

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Headaches

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Sleep Disturbances

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Unusual Tiredness/Fatigue

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Irritability

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Depression

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Anxiety/ Tension/ Nervousness

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Mood Swings / Changes

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Confusion / Difficulty Concentrating

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Forgetfulness / Short-Term Memory Loss

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Angry Outburst/ Arguments/ Violent Tendencies

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Crying Easily

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Muscle Cramps/ Spasms

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Acne / Pimples / Skin Flushing

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
New Facial Hair

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Dry Skin / Hair

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Frequent Urinary Tract Infection (UTI)

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Urinary Frequency

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Vaginal Dryness

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Abnormal Bleeding

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Uncomfortable Intercourse

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Loss of Sexual Feeling / Desire

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Loss of arousability & Capacity for Orgasm

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Breast tenderness / sensitivity

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Cravings for Sweet or Salty Foods

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Increased Appetite and/or weight gain

1

2

3

4

5

6

7

8

9

10

1 is No impact at all on your daily life, 10 is Severe impact on your daily life
Thank you for taking time to complete this comprehensive form. One of our pharmacist will review your submission and then contact you to discuss next steps and to schedule an appointment.
Should be Empty:

Uptown Pharmacy Hormone Consultation

Patient Medical History

For the following symptoms, please rate their impact on your daily life

Thank you for taking time to complete this comprehensive form. One of our pharmacist will review your submission and then contact you to discuss next steps and to schedule an appointment.