Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Name
*
First Name
Last Name
Birthdate
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Age
*
Address
*
Street Address
Street Address Line 2
City
State
Zip
Email
*
Phone Number
*
Format: (000) 000-0000.
Height:
*
Weight:
*
Desired Weight:
*
*
Rows
Answer
How Often and how much?
Do you use Tobacco?
Yes
No
Do you use Alcohol
Yes
No
Do you use caffeine?
Yes
No
Do you exercise?
Yes
No
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, insomia, etc).
*
Current Prescription Medications (Including hormones):
*
Rows
Medication Name and Strength
Date Started
How Often per day
1.
2.
3.
4.
5.
Back
Next
Patient Name:
*
*
Rows
List Hormones Previously Taken
Date Started
Date Stopped
Reason
1.
2.
3.
4.
Have you ever used oral contraceptives (birth control)?
*
Yes
No
If you experience any problems, please describe:
*
How many pregnancies have you had?
*
How many children?
*
Any interrupted pregnancies?
*
Yes
No
If yes, please explain:
*
Have you had a tubal ligation:
*
Yes
No
If yes, date of surgery:
*
Have you had a hysterectomy?
*
Yes
No
If yes, date of surgery:
*
Reason:
*
Do your ovaries remain?
*
Yes
No
Do you have a family history of any cancers or osteoporosis?
*
Yes
No
Please list the family members(s):
*
Have you had any of the following tests performed?
*
Rows
Yes
No
Date:
Outcome:
Mammography
PAP Smear
Bone Density
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?
*
Yes
No
Have you ever had what YOU would consider to be abnormal cycles?
*
Yes
No
Explain:
*
When was your last period?
*
How many days did it last?
*
Do you or have you ever suffered from Premenstrual Syndrome (PMS) symptoms?
*
Yes
No
Explain:
*
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Patient Name:
*
*
Rows
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:
*
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Patient Name:
*
What are your goals for taking Hormone Replacement Therapy?
*
Doctor that we should contact for this therapy:
Name:
*
Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please verify that you are human
*
Math Challenge
*
Submit
Should be Empty: