Hormone Consultation Form

The Art of Medicine

1335 Mt. Vernon St.

Philadelphia, PA 19123

support@theartofmed.com
Female Hormone Consultation Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
*An at-home test kit must be ordered in order to complete a consultation.

Order below or on our website!

Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Bio-Identical Hormone Replacement Therapy Patient Consent
I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages.

I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all hormone levels or other diagnostic testing by a physician, my primary care physician, or other specialist. I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc.

I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as to not being treated. Those risks and potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of bio-identical and other hormone treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of bio-identical hormone therapy.

I have been informed that insurance companies may not pay for physician evaluation, laboratory testing, and medications. I therefore agree to pay for all services including physician evaluation, laboratory tests and pharmacy charges, with the understanding that I may not be reimbursed by my insurance company.

I certify this form has been fully explained to me and that I have read it. I have been educated on the benefits, risks, and possible adverse reactions associated with bio-identical hormone replacement therapy. I have been given the opportunity to ask any questions about hormone replacement therapy, potential complications, required testing, and costs and have had them answered to my satisfaction. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I fully understand what I am agreeing to and hereby request and consent to treatment using bioidentical hormone replacement therapy.
I have read and agree to the terms above*

Clear

Confidential Female Hormone Evaluation

This must be complete prior to finalizing your appointment time.
Date of Birth*

MonthDayYear
Date
Height*
Weight*
Desired Weight*
Do you use tobacco? If so, how often and how much?*
Do you drink alcohol? If so, how often and how much?*
Do you use caffeine? If so, how often and how much?*
Do you exercise? If so, please describe.*
Have you ever had a panic attack? If so, please elaborate (dates/frequency):*
Do you have OCD?*
Any diagnosis of a mental illness? If so, please describe.*
Have you ever had a head injury/concussion? If so, please describe.*
How frequent are your bowel movements?*
Typical number of hours slept per night:*
Is your sleep uninterrupted?*
Describe your diet as best as possible.*
What would you like to change about your current dietary choices?*
Please list any drug allergies.*
Please list any food allergies.*
Are you still cycling (menstruating)?*

YesNoOther
If yes, what was the date of your last period?
Please list all non-prescription medications you are taking (vitamins, supplements, herbals, etc). *
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). *
Please list all prescription medications you are taking. Please include name, strength, and frequency.*
Please list any hormones you have previously taken.*
Have you ever used oral contraceptives (birth control)? If you experienced any problems, please describe.*
How many pregnancies have you had?*
How many children have you had?*
Any interrupted pregnancies? Please explain.*
Have you had tubal ligation?*

YesNo
Have you had a hysterectomy?*

YesNo
Do your ovaries remain?*

YesNo
Have you had an endometrial ablation?*

YesNo
When was your last mammogram?*

Less than 1 year ago1-3 years agoMore than 3 years agoI have never had a mammogram
When was your last PAP smear?*

Less than 1 year ago1-3 years agoMore than 3 years agoI have never had a mammogram
When was your last bone density scan?*

Less than 1 year ago1-3 years agoMore than 3 years agoI have never had a mammogram
Have you ever had what YOU would consider to be abnormal cycles? Please explain. *
Do you experience hot flashes? If so, when and how often?*

Please select the intensity of each symptom. Rate with 0 being absent, and 3 being severe.*

	0	1	2	3
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
Difficulty Reaching Climax
Stress
Sugar Cravings
Excess Facial/Body Hair

What are your top 3 goals for taking Hormone Replacement Therapy?*
Which doctor should we contact for this therapy?*

I have a provider I would like to use.I would like to see your recommended provider.
If you would like to use your own provider, please list their name.
I have ordered my at-home hormone test from the pharmacy:*

YesNo

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Consultation

$95.00

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Female Hormone Consultation Form

*An at-home test kit must be ordered in order to complete a consultation.

Bio-Identical Hormone Replacement Therapy Patient Consent

Confidential Female Hormone Evaluation