HRT Questionaire
(Hormone Replacement Therapy - Female)
Date
-
Month
-
Day
Year
Today's Date
Date of Birth
-
Month
-
Day
Year
Date of Birth
Name
First Name
Last Name
Phone Number
Please enter best phone number.
Format: (000) 000-0000.
Email
example@example.com
Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
1. Hot flashes, sweating (episodes of sweating)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
5. Irritability (feeling nervous, inner tension, feeling aggressive)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
6. Anxiety (inner restlessness, feeling panicky)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
8. Sexual problems (change in sexual desire, in sexual activity and satisfaction)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
9. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
10. Dryness of vagina (sensation of dryness or burning in the vagina difficulty with sexual intercourse)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)
*
None
1
2
3
4
Extremely Severe
5
1 is None, 5 is Extremely Severe
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
*
Yes
No
Do you have daily bowel movements?
*
Yes
No
Do you have gas, bloating or abdominal pain after eating?
*
Yes
No
Weight in lbs
Please select your WEEKLY Activity Level based on this criteria - Physical activity that accelerates heart rate / Breathlessness
*
0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days per week (High)
Please list any prior hormone therapy?
Date of last mammogram
-
Month
-
Day
Year
Date
Result of last mammogram
Submit
FOR OFFICE USE ONLY
CHART ID
DOB
APPOINTMENT DATE
Should be Empty: