Female BHRT Health Summary

Female Information and Health Summary
Date

MonthDayYear
Date
Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Who referred you to us?
Please List Your Healthcare Provider to Contact Regarding Hormone Therapy
Name
Specialty
Address
Phone
Format: (000) 000-0000.
Fax
Do You Have Any Known Medication Allergies?
Please List Any Medications You Are Currently Taking, Including Vitamins, Natural Supplements, or Non-Prescription Medications (Doses of any hormones you are taking are necessary, because that is the current baseline to make a recommendation to your doctor):
Please List Medications and Doses Here:
BadFairGoodVery Good
Exercise: type of activity, how frequent, and for how long?
Height in Feet blanks and Inchesblank
Weight in Pounds
Employer and Job Title
NoneMildModerateSevereExtremely Severe
Breast CancerUterine CancerOvarian CancerOther CancerDiabetesHeart DiseaseOsteoporosisAlzheimer's DiseaseThyroid Disease
Please describe which family member had which disease state:
AsthmaCancerDepressionDiabetesHeadaches/MigrainesHeart ConditionHigh Blood PressureOsteoporosis/OsteopeniaFibromyalgiaArthritisVaricose VeinsKidney DisorderThyroid DisorderHigh CholesterolClotting DisorderGallbladder DiseaseFracturesEpilepsyLiver DisorderEating DisorderUlcersChronic Fatigue SyndromeOther
YesNo
If yes, when was your hysterectomy?
YesNo
If yes, when were your ovaries removed?
YesNo
YesNo
If yes, when was your abnormal Pap?
YesNo
If yes, how often do you perform self-breast exams?
YesNo
YesNo
What is your current method of birth control & how long has it been in use?
Past method of birth control & any problems?
Number of pregnancies?
Number of deliveries?
Number of multiple births?
Number of miscarriages?
Sexual ProblemsCervical DysplasiaVaginal DrynessVaginal InfectionsPelvic Infectionsa PCOS DiagnosisIncreased Facial &/or Body Hair GrowthCervical CancerPainful IntercourseUterine FibroidsLack of EnergyHSV (vaginal herpes)Lack of Sex DriveOvarian CystsBreast FibroidsHPV (vaginal warts)Inability to Reach Climax
RegularIrregularSporadicNo Periods
LightHeavy
YesNo
When was your last period?
How long is your cycle?
YesNo
YesNo
If yes, please list PREVIOUS & CURRENT hormones used, DOSES, and any side effects here: (Doses are extremely important to this process!)
Have you tried alternative therapies or taken any herbal or homeopathic products?
How did you become interested in bio-identical hormones?
Swollen BreastsAnxiety/IrritabilityIrregular MensesInfertilityWeight GainMood SwingsPMSJoint PainFood CravingsHeadachesCrampingAcneLow Sex DriveDepressionFuzzy ThinkingLow Energy
Hot FlashesDry SkinFoggy ThinkingPainful IntercourseNight SweatsYeast InfectionsBone LossWeight GainInsomniaHeart PalpitationsLow Sex DriveVaginal Dryness/AtrophyMemory LapsesDepressionHeadaches
DepressionJoint PainHeart PalpitationsFibromyalgiaUrinary IncontinenceLow Sex DriveMemory LapsesVaginal DrynessLow EnergyBone LossMuscle WeaknessThinning Skin/Scalp Hair
If you have headaches, how many days per week?
If you have night sweats, how many days per week?
If you have insomnia, how many days per week?
Are there any other symptoms you'd like to add?
What TOP 3 symptoms would you like resolved first?
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NoneMildModerateSevere
NeverInfrequentlySometimesMost of the TimeAlways
NeverInfrequentlySometimesMost of the TimeAlways
NeverInfrequentlySometimesMost of the TimeAlways
NeverInfrequentlySometimesMost of the TimeAlways
NeverInfrequentlySometimesMost of the TimeAlways
Should be Empty: