CONFIDENTIAL FEMALE HORMONE EVALUATION

CONFIDENTIAL FEMALE HORMONE EVALUATION
Today’s Date

MonthDayYear
Date
Name
Birthdate

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email
example@example.com
Height
Weight
Desired Weight
Do you use tobacco?

YesNo
Do you use alcohol?

YesNo
Do you use caffeine?

YesNo
Do you exercise?

YesNo
Allergies: Please list any allergies and describe the reaction that occurred
Drugs
Foods
Other
Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements.)
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc.)
Current Prescription Medications (including hormones):
List Hormones Previously Taken:
Have you ever used oral contraceptives (birth control)?

YesNo
If you experienced any problems, please describe
How many pregnancies have you had?
How many children?
Any Interrupted pregnancies?

YesNo
If yes, please explain
Have you had a tubal ligation:

YesNo
If yes, date of surgery

MonthDayYear
Date
Have you had a hysterectomy?

YesNo
If yes, date of surgery

MonthDayYear
Date
Reason
Do your ovaries remain?

YesNo
Do you have a family history of any cancers or osteoporosis? Please list the family member(s):
Have you had any of the following tests performed?
Mammography

YesNo
Date

MonthDayYear
Date
Outcome
PAP Smear

YesNo
Date

MonthDayYear
Date
Outcome
Bone Density

YesNo
Date

MonthDayYear
Date
Outcome
What age did your period start?
How many days is/was your cycle (Example: 28)
Is/was your menstrual flow heavy or light?
Any clots?

YesNo
Have you ever had what YOU would consider to be abnormal cycles?

YesNo
Explain
When was your last period?
How many days did it last?
Do you or have you ever suffered from Premenstrual Syndrome (PMS) symptoms?

YesNo
Explain

Symptoms

	Absent	Mild	Moderate	Severe
Hot Flashes
Night Sweats
Vaginal Dryness
Incontinence
Bleeding Changes
Fibrocystic Breast
Weight Gain
Fluid Retention
Dry Skin/Hair
Hair Loss
Anxiety
Depression
Mood Swings
Irritability
Headaches
Breast Tenderness
Cramps
Difficulty Falling Asleep
Difficulty Staying Asleep
Fatigue
Loss of Memory
Foggy Thinking
Acne
Arthritis
Decreased Sex Drive
Harder to Reach Climax
Stress

Other Symptoms
What are your goals for taking Hormone Replacement Therapy?
1.
2.
3.
Doctor that we should contact for this therapy:
Name
Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
*** Please include a copy of all relevant lab work, especially hormone levels that you have recently obtained.
Should be Empty:

CONFIDENTIAL FEMALE HORMONE EVALUATION

Allergies: Please list any allergies and describe the reaction that occurred

Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements.)

Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc.)

Have you had any of the following tests performed?

What are your goals for taking Hormone Replacement Therapy?

Doctor that we should contact for this therapy:

*** Please include a copy of all relevant lab work, especially hormone levels that you have recently obtained.