HRT Female - Kucine

HRT Questionaire

(Hormone Replacement Therapy - Female)
Date

MonthDayYear
Today's Date
Date of Birth

MonthDayYear
Date of Birth
Name

First NameLast Name
Phone Number
Please enter best phone number.
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)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness) *

1

2

3

4

5

1 is None, 5 is Extremely Severe
3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early) *

1

2

3

4

5

1 is None, 5 is Extremely Severe
4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
5. Irritability (feeling nervous, inner tension, feeling aggressive)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
6. Anxiety (inner restlessness, feeling panicky) *

1

2

3

4

5

1 is None, 5 is Extremely Severe
7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
8. Sexual problems (change in sexual desire, in sexual activity and satisfaction) *

1

2

3

4

5

1 is None, 5 is Extremely Severe
9. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
10. Dryness of vagina (sensation of dryness or burning in the vagina difficulty with sexual intercourse) *

1

2

3

4

5

1 is None, 5 is Extremely Severe
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)*

1

2

3

4

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?*

YesNo
Do you have daily bowel movements?*

YesNo
Do you have gas, bloating or abdominal pain after eating? *

YesNo
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?
FOR OFFICE USE ONLY
CHART ID
DOB
APPOINTMENT DATE
Should be Empty:

HRT Questionaire

Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.

FOR OFFICE USE ONLY