FEMALE BioTE Hormone Pellet Questionnaire

FEMALE BioTE Hormone Pellet Questionnaire
Patient Name*

First NameLast Name
Patient Age*
Patient Date of Birth*

MonthDayYear
Date
Patient Weight
Is the patient currently pregnant or trying to conceive:

YesNo
Does the patient have a uterus:

YesNo
Does the patient still have a menstrual period:

YesNo
How long has it been since the last menstrual period:
What is the patient using for birth control?
Is the patient a smoker?

YesNo
Is the patient currently on hormone replacement therapy?*

YesNo
If yes to the above question What Kind?
Is the patient currently on thyroid medication?

YesNo
If yes to the above question What Kind?
Is the patient currently on a statin?

YesNo
Does this patient have a personal history of breast cancer?

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

YesNo
Does this patient have a history of endometriosis?

YesNo
Does this patient have a history of fibrocystic breast disease?

YesNo
Does this patient have a history of polycystic ovarian syndrome?

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

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

YesNo
Is this patient currently experiencing acne?

YesNo
Is this patient currently experiencing any breast tenderness?

YesNo
Is this patient currently experiencing any facial hair?

YesNo
Does this patient have premenstrual migraine headaches?

YesNo
Is this patient experiencing hot flashes?

YesNo
Date of Last Mammogram

MonthDayYear
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:   *
Should be Empty: