FEMALE BioTE Hormone Pellet Questionnaire

Patient Name

First NameLast Name

Patient Age

Patient Date of Birth

Date

Patient Weight

Is the patient currently pregnant or trying to conceive:

Does the patient have a uterus:

Does the patient still have a menstrual period:

How long has it been since the last menstrual period:

What is the patient using for birth control?

Is the patient a smoker?

Is the patient currently on hormone replacement therapy?

If yes to the above question What Kind?

Is the patient currently on thyroid medication?

If yes to the above question What Kind?

Is the patient currently on a statin?

Does this patient have a personal history of breast cancer?

Does this patient have a personal history of epilepsy or seizures?

Does this patient have a history of endometriosis?

Does this patient have a history of fibrocystic breast disease?

Does this patient have a history of polycystic ovarian syndrome?

Does this patient have a history of uterine fibroids or polyps?

Does this patient have a history of Hashimoto's thyroiditis?

Is this patient currently experiencing acne?

Is this patient currently experiencing any breast tenderness?

Is this patient currently experiencing any facial hair?

Does this patient have premenstrual migraine headaches?

Is this patient experiencing hot flashes?

Date of Last Mammogram

Date

Was it normal?

FOR THE PROVIDER TO FILL OUT:

The date that the patient's lab work was done:   Date
Total testosterone level:   Type a label
FSH level:
TSH:
Free T3:
Free T4:   Type a label
Total T4:   Type a label
Thyroid peroxidase antibodies:   Type a label
Vitamin D level:   Type a label
eGFR:   Type a label
TESTOSTERONE DOSE:   Type a label
THYROID DOSE:   Type a label
ESTRADIOL DOSE:
PROGESTERONE DOSE:   Type a label

This is a fill in the blanks field. Please add appropriate blank fields and text.

Patient Name name*
Patient Age:   *
Date of Birth:   Date*
Patient's weight:   *