Female Patient Hormone Questionnaire

Female Patient Hormone Questionnaire
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Full Name*

First NameLast Name
Please check all that apply to you:

I am sexually active.My sex life has suffered.I want to be sexually active.I have not been able to have an orgasm.I have completed my family.I have no plans to attempt conception within 2 years.I am suspicious of a pregnancy.I have had issues with anesthesia. If yes, please explain below.I am currently on hormone replacement therapy. If yes, please explain below.In the past, I was on hormone replacement therapy. If yes, please explain below.In the past, I have had a stroke, pulmonary embolism, deep vein thrombosis, and/or blood clots. If yes, please explain below.
Explain how you have had issues with anesthesia.
Explain your current use of hormone replacement therapy.
Explain your past use of hormone replacement therapy.
Explain if you have had a stroke, pulmonary embolism, deep vein thrombosis, and/or blood clots.

HRT Checklist for Women - Please indicate degree of symptom.

	Never	Mild	Moderate	Severe
Fatigue
Joint pain / Muscle Ache
Sleep Problems / Insomnia
Mood Changes / Irritability
Anxiety
Depressed Mood
Declining Mental Ability / Focus / Concentration / Brain Fog
Weight Gain / Belly Fat / Inability to Lose Weight
Migraines / Headaches
Decreased Sex Drive / Libido
Difficult to Climax Sexually
Vaginal Dryness
Vaginal Laxity (Looseness)
Hot Flashes
Night Sweats
Dry and Wrinkled Skin
Hair Loss
Cold all the Time
Loss of Urine (Incontinence)
Excessive Nighttime Urination
Constant Urge to Urinate

Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).*

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