Women's HRT

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WOMEN'S Questionnaire
This form is an abbreviated symptom profile.

To expedite dose recommendations, please fax to (888-454-9135) your medication profile, history and physical.

Please notate in the fax the reason you are faxing information. We want to make sure it is associated with your form.
Name

First NameLast Name
Date Submitted

MonthDayYear
Date
Date of Birth

MonthDayYear
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Preferred method of contact*

PhoneEmail
PHYSICIAN / PRESCRIBER
Name

First NameLast Name
Please answer the following questions.
Do you still have your period?

YesNoIrregular
Uterus removed (hysterectomy)?

YesNo
Ovaries removed (oophorectomy)?

YesNo
When was your last mammogram?
Current birth control method?
Record NA if not applicable
History of breast cancer?

YesNo
Have you been diagnosed with a thyroid disorder?

YesNo
Do you currently smoke or use tobacco products?

YesNo
Medical & Social History
Medical History - Select all that apply

HIgh Blood PressureAlcohol UseHigh CholesterolSexual DysfunctionCardiovascular DiseaseInsomniaDiabetes MellitusMalnutritionOsteoporosisDepressionCancerTobacco UseAsthma / COPDOther
If you selected Cancer, what type?
Other medical condition(s)
Are you interested in discussing Anti-Aging skin care?

YesNoOther
MEDICATIONS
Medication History
List all prescription and non-prescription medications you are currently taking. (Including vitamins, herbals, and supplements). Record "None" if applicable.
Drug Allergies
List all drug allergies (Including vitamins, herbals, and supplements). Record "None" if applicable.
SYMPTOMS
SELECT A BOX FOR EACH SYMPTOM that best describes how you have been feeling for the past few months.
- None - symptom not present
- Mild - present but not distressing
- Moderate - distressing, but not interfering with daily life
- Severe - very distressing, interferes with daily life
IT IS ENCOURAGED FOR THE PATIENT TO KEEP A COPY OF THIS BASELINE SYMPTOM PROFILE TO BETTER MONITOR THE PROGRESS OF THE THERAPY.
Hot flashes

NoneMildModerateSevere
Night sweats

NoneMildModerateSevere
Light-headed feelings / dizziness

NoneMildModerateSevere
Headaches

NoneMildModerateSevere
Sleep disorders / sleeplessness

NoneMildModerateSevere
Unusual tiredness / fatigue

NoneMildModerateSevere
Irritability

NoneMildModerateSevere
Depression

NoneMildModerateSevere
Anxiety / tension / nervousness

NoneMildModerateSevere
Mood swings / mood changes

NoneMildModerateSevere
Confusion / difficulty concentrating

NoneMildModerateSevere
Angry outbursts / arguments / violent tendencies

NoneMildModerateSevere
Crying easily

NoneMildModerateSevere
Backache

NoneMildModerateSevere
Joint pains

NoneMildModerateSevere
Muscle pains

NoneMildModerateSevere
Muscle cramps / spasms

NoneMildModerateSevere
Problems with wound healing time

NoneMildModerateSevere
Acne / pimples / skin flushing

NoneMildModerateSevere
Dry skin / dry hair

NoneMildModerateSevere
Crawling feeling under skin

NoneMildModerateSevere
Frequency Urinary Tract Infection (UTI)

NoneMildModerateSevere
Urinary frequency

NoneMildModerateSevere
Vaginal dryness

NoneMildModerateSevere
Abnormal bleeding

NoneMildModerateSevere
Pelvic pain, pressure, fullness, or bloating

NoneMildModerateSevere
Uncomfortable intercourse

NoneMildModerateSevere
Loss of sexual feeling / desire

NoneMildModerateSevere
Loss of arousability and capacity for orgasm

NoneMildModerateSevere
Loss of sexual sensitivity

NoneMildModerateSevere
Loss of vitality

NoneMildModerateSevere
Nipple sensitivity

NoneMildModerateSevere
Discharge or leaking from nipples

NoneMildModerateSevere
Breast tenderness

NoneMildModerateSevere
Loss of pubic hair

NoneMildModerateSevere
Swelling of hands, ankles, or breasts

NoneMildModerateSevere
Heart palpitations

NoneMildModerateSevere
Shortness of breath

NoneMildModerateSevere
Food / sweets / salt cravings

NoneMildModerateSevere
Increased appetite / weight gain

NoneMildModerateSevere
Comments
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WOMEN'S Questionnaire

PHYSICIAN / PRESCRIBER

Please answer the following questions.

MEDICATIONS

SYMPTOMS