Female BHRT Health Summary

Female Information and Health Summary

Date

Name

Date of Birth

Date

Address

Street Address Line 2

City/State/ZIP

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:

Is your Diet:

Exercise: type of activity, how frequent, and for how long?

Height in Feet blanks and Inchesblank

Weight in Pounds

Employer and Job Title

What is Your Perceived Stress Level?

Family History--Check all that apply for a direct family member:

Please describe which family member had which disease state:

Past or Present Personal Medical Conditions--Please check all that apply:

Have you had a hysterectomy?

If yes, when was your hysterectomy?

Have your ovaries been removed?

If yes, when were your ovaries removed?

Have you ever had a tubal ligation?

Have you ever had an abnormal Pap?

If yes, when was your abnormal Pap?

Do you perform self-breast exams?

If yes, how often do you perform self-breast exams?

Are you sexually active?

Are you trying to get pregnant?

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?

Have you ever had.......(Check all that apply)

Menstrual History--Present state of menstruation:

Past/Present State of Menstrual Flow:

Have you missed periods altogether?

When was your last period?

How long is your cycle?

Do you have bleeding between periods?

Have you ever taken hormones before?

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?

Please check ALL symptoms of Low Progesterone:

Please check ALL symptoms of Low Estrogen:

Please check ALL symptoms of Low Testosterone:

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?

Intensity of hot flashes, perspiration, and/or chilly sensations in past few months:

Degree of insomnia, or restless/fragmented sleep in past few months:

Degree of Irritability, feeling anxious or apprehensive in past few months:

Intensity of feeling depressed, unhappy, and/or being miserable without obvious reason in past few months:

Degree of sensations of dizziness or swimming in the head in past few months:

Degree of weariness of mind & body with desire for rest; disinclination to make further efforts in past few months:

Degree of pain of any kind affecting joints or muscles in past few months:

Intensity of headaches of any kind (tension, migraine, etc.) in past few months:

Degree of acceleration of heartbeat or fluttering/pounding heartbeat in sitting or resting position in past few months:

Degree of thinning or loss of scalp hair in past few months:

Have you had vaginal burning or itching?

Have you ever had painful urination or increased frequency of urination?

Have you had leaking of urine when coughing, laughing, sneezing, or on hard work?

Have you ever had leaking of urine when walking, running, climbing steps, or on light work?

Have you had leaking of urine, regardless of activity, even when in a lying position?