Confidential Female Hormone Evaluation Form English

CONFIDENTIAL FEMALE HORMONE EVALUATION

Please fill out the blank spaces
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Birthdate: blanks Age: blank Height: blanks Weight blank Desired Weight: blanks

Do you use tobacco?

Yes. If yes, How often and How much?No
Type here: blanks
Do you use alcohol?

Yes. If Yes, How Often and How much?No
Type here: blanks
Do you use caffeine?

Yes. If Yes, How Often and How much?No
Type here: blanks
Do you excercise?

Yes. If yes, How Often and How much?No
Type here: blanks
Allergies: Please list any allergies and describe the reaction that ocurred.
Drugs: blanks
Foods: blank
Other: blank
Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):
Name blanks Strength/ #tablets/frequency blank
Name blanks Strength/ #tablets/frequency blank
Name blanks Strength/ #tablets/frequency blank
Name blanks Strength/ #tablets/frequency blank
Name blanks Strength/ #tablets/frequency blank
Name blanks Strength/ #tablets/frequency blank
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include: Heart diseases, high blood pressure, depression, ulcers, arthritis, insomnia, etc).
blanks
blank
blank
blank
blank
Current Prescription Medications (including hormones)
Medication Name and Strength:blanks Date Started/ How often per day blank

Medication Name and Strength:blanks Date Started/ How often per day blank

Medication Name and Strength:blanks Date Started/ How often per day blank

Medication Name and Strength:blanks Date Started/ How often per day blank
List Hormones Previously Taken: blanks Date Started/Stopped & reason blank .

List Hormones Previously Taken: blanks Date Started/Stopped & reason blank .

List Hormones Previously Taken: blanks Date Started/Stopped & reason blank .
Have you ever used oral contraceptives (birth control)?

YesNo
If you experienced any problems, please describe: blanks
How many pregnancies have you had? blanks How many children? blank
Any interrupted pregnancies?

YesNo
If yes, please explain: blanks blank
Have you had a tubal ligation:

YesNo
If yes, date of surgery: blanks
Have you had a hysterectomy?

YesNo
If yes, date of surgery: blanks Reason:blank
Do your ovaries remain?

YesNo
Do you have a family history of any cancers or osteoporosis? Please list the family members: blanks blank

Have you had any of the following tests performed?

Rows	Yes	No	During las 12 months?	2-4 Years ago?	More than 5 years ago
Mammography
PAP Smear
Bone Density

What age did your period start? How many days is/was your cycle(Example:28)
What age did your period start? How many days is/was your cycle(Example:28)
Is/was your menstrual heavy or light? blanks Any clots? blank
Have you ever had what YOU would consider to be abnormal cycles?

YesNo
Explain: blanks
When was your last period? blanks How many days did it last? blank
Do you or have you ever suffered from Premenstrual Syndrome (PMS) SYMPTOMS?blanks Explain: blank

Please mark based on your criteria

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

What are your goals for taking Hormone Replacement Therapy?
Doctor that we should contact for this therapy: Name/ Phone/ Address
Should be Empty:

CONFIDENTIAL FEMALE HORMONE EVALUATION

Current Prescription Medications (including hormones)