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
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Preferred method of contact
PHYSICIAN / PRESCRIBER
Name

First NameLast Name
Please answer the following questions.
Do you still have your period?
Uterus removed (hysterectomy)?
Ovaries removed (oophorectomy)?
When was your last mammogram?
Current birth control method?
Record NA if not applicable
History of breast cancer?
Have you been diagnosed with a thyroid disorder?
Do you currently smoke or use tobacco products?
Medical & Social History
Medical History - Select all that apply

Other
If you selected Cancer, what type?
Other medical condition(s)
Are you interested in discussing Anti-Aging skin care?

Other
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
Night sweats
Light-headed feelings / dizziness
Headaches
Sleep disorders / sleeplessness
Unusual tiredness / fatigue
Irritability
Depression
Anxiety / tension / nervousness
Mood swings / mood changes
Confusion / difficulty concentrating
Angry outbursts / arguments / violent tendencies
Crying easily
Backache
Joint pains
Muscle pains
Muscle cramps / spasms
Problems with wound healing time
Acne / pimples / skin flushing
Dry skin / dry hair
Crawling feeling under skin
Frequency Urinary Tract Infection (UTI)
Urinary frequency
Vaginal dryness
Abnormal bleeding
Pelvic pain, pressure, fullness, or bloating
Uncomfortable intercourse
Loss of sexual feeling / desire
Loss of arousability and capacity for orgasm
Loss of sexual sensitivity
Loss of vitality
Nipple sensitivity
Discharge or leaking from nipples
Breast tenderness
Loss of pubic hair
Swelling of hands, ankles, or breasts
Heart palpitations
Shortness of breath
Food / sweets / salt cravings
Increased appetite / weight gain
Comments
Please upload current picture identification (drivers license, state identification, passport, etc...)

Cancelof
Should be Empty:

WOMEN'S Questionnaire

PHYSICIAN / PRESCRIBER

Please answer the following questions.

MEDICATIONS

SYMPTOMS