Female Checklist - BEFORE HRT
Name
*
Cell
*
E-Mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
DOB
*
-
Month
-
Day
Year
Date
Select a number for the symptom you are currently experiencing.
0: None 1: Mild 2: Moderate 3: Severe 4: Extremely Severe
Hot flashes, sweating (episodes of sweating)
*
Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
*
Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
*
Irritability (feeling nervous, inner tension, feeling aggressive)
*
Increased need for sleep, often feeling tired
*
Anxiety (inner restlessness, feeling panicky)
*
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
*
Sexual problems (change in sexual desire, in sexual activity and satisfaction)
*
Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
*
Decrease in muscular strength (feeling of weakness)
*
Joint and muscular discomfort (pain in the joints, rheumatoid complaints)
*
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
*
Please share any additional comments about your symptoms you would like to address.
Cold hands and feet?
*
Yes
No
Daily bowel movements?
*
Yes
No
Do you have gas, bloating or abdominal pain after eating?
*
Yes
No
Breast Cancer?
*
Yes
No
Currently on Birth Control?
*
Yes
No
Hysterectomy?
*
Yes
No
PCOS?
*
Yes
No
Smoker
*
Yes
No
Adult Acne?
*
Yes
No
Currently taking ADD meds (Adderall, Concerta, Vyvanse, etc.)?
*
Yes
No
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)
Last mammogram
*
Within Guideline Recommendation
Waiver received
Still having menstrual cycles?
*
No
Irregular
Regular
Not within the past 12 months
Please select what applies.
Currently on Testosterone
Currently on Estrogen
Previously on Estrogen
Please describe any prior hormone therapy.
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