Womens Health Hormone Self Assessment

Womens' Health

Hormone Self-Assessment

If you are interested in pursuing hormone replacement therapy, please complete this form, and one of our staff will reach out to you to discuss options and next steps.
Patient Name
Date of Birth
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When was your last menstrual cycle?
Have you had a hysterectomy?
If yes, partial or full (ovaries removed)?
Are you on any birth control or hormone replacement medications?
If yes, please list any prescription or over-the-counter meds:
Do you have a history of any of the following (check all that apply):
If you checkmarked Other, please specify what other conditions:
If you checkmarked Cancer, please indicate what type:

To what degree do you experience the following?

Rows	None	Slightly	Moderate	Severe	Extreme
Anxious
Brain Fog
Can't Sleep
Depressed/Unhappy
Difficulty Concentrating
Difficulty Remembering Things
Dry Hair/Skin
Fatigue/Loss of Energy
Frequent Urinary Tract Infections
Headaches
Hot Flashes
Incontinence
Lack of Sexual Desire
Moodiness/Emotional Swings
Night Sweats
Painful Intercourse
Painful or Swollen Breasts
Vaginal Dryness
Weight Gain/Bloating

Physician name
Physician Phone:
Format: (000) 000-0000.
My signature below indicates my consent for Parkland Pharmacy to share this assessment with my physician and to request lab results if applicable.
(Patient Signature)
(Date)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: