HORMONE REPLACEMENT THERAPY
FEMALE MEDICAL HISTORY
Are you currently:
*
Please Select
Pregnant
Trying to conceive
Breastfeeding
Menopausal
None of the Above
What type of birth control do you use?
*
Please Select
Abstinence
Depo Provera
IUD
BCP
Menopause
Hysterectomy
None
If you experienced any problems while taking oral contraceptives please explain below
*
Are you currently or have you been previously diagnosed with any of the following (Check all that apply):
*
Please Select
Blood Clots
Uterine Fibroids
Breast Cancer (self)
Atypical Ductal Hyperplasia
Breast Cancer (Family)
Abnormal Vaginal bleeding
Endometrial Cancer
None of the Above
Please list Hormones, date initiated and brief reason:
Other
Date Stopped
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many Pregnancies have you had
*
How many Children do you have
*
Have you had a hysterectomy?
*
Yes
No
If Yes date of surgery
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If Yes please explain reason
Have you had any of the following tests performed? or NA
Please Select
Mammogram
PAP Smear
Bone Density
Pending
Never
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Results
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Results
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Results
Other Tests:
SYMPTOMS:
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HRT Client Consultation Form
Todays Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do You:
*
Rows
Yes
No
Occassionally
Never
Use Tobacco?
Do you vape?
Drink alcohol?
Consume Caffeine?
Exercise?
Do you have an allergies?
Rows
Mild
Moderate
Severe
Yes
No
What allergy?
Please check all/any of the following health conditions you have experienced and/or that you are currently experiencing:
Rows
Select all that Apply
Cancer
High Blood Pressure
Arthritis
HIV/AIDS
Asthma
Seizure Disorder
Depression
Blood Clotting Abnormality
ALS
Heart Conditions
Auto Immune Disease
Myasthenia Gravis
Lambert-Eaton Syndrome
Diabetes
High cholesterol
Gallbladder Disease
Immune Deficiency
Kidney disease
Hepatitis
Thyroid Imbalance
Orthopedic Disorder
Parkinson
Multiple Sclerosis (MS)
Neurological Disorder
None of the Above
Are you currently taking any medications?
Please Select
Yes
No
If yes, please list all medications you are taking including Vitamins, supplements, hormones, prescribed medications and over the counter.
Have you ever been Hospitalized or received acute medical care, including Surgeries in the past year? If Yes, please specify all surgical procedure and approximate dates
Primary Care Physician and phone#
File Upload- Please upload your most recent labs
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