Female Hormone Optimization Form

Female Hormone Optimization Form

Whether you’re exploring hormone therapy, preparing for your first appointment, or checking in for a follow-up, this form helps us personalize your care.
Reason for Completing This Form

I’m interested in learning more (no appointment yet)I’m preparing for my first hormone therapy appointmentI’m an established patient completing this form for a follow-up visit
Patient Information
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Current Weight (lbs)*
Height*
Current Symptom Severity Rating (Past 2 Weeks)

Please rate how much each symptom has affected you over the past two weeks. Scale: 1 = Not a Problem at All; 2 = Mild Problem; 3 = Moderate Problem; 4 = Significant Problem; 5 = Worst It’s Ever Been
General Health Self-Assessment
Hormone Symptom Rating

For each symptom below, rate how it has affected you over the past few weeks.If you do not experience the symptom, select 1 (None).

I experience hot flashes or night sweats.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel heart palpitations or chest tightness.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have trouble falling or staying asleep.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel tired or low on energy.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel down or depressed.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel irritable or easily agitated.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel anxious or on edge.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have trouble focusing or feel mentally foggy.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have less interest in sex or a lower libido.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I experience urinary urgency, frequency, or leakage.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I experience vaginal dryness or discomfort.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I experience joint or muscle pain.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

General Health Questions

Please answer the following questions about your overall health and lifestyle.

How would you rate your overall health right now? *

	1	2	3	4	5

1 is Excellent, 5 is Extremely Poor

Do you often have cold hands or feet?*

YesNo
Do you have a bowel movement every day?*

YesNo
Do you experience gas, bloating, or abdominal discomfort after eating?*

YesNo
How often do you engage in physical activity that increases your heart rate or causes breathlessness?*

0-1 day per week2-3 days per weekMore than 3 days per week
Are you currently taking ADD/ADHD medications (e.g., Adderall, Concerta, Vyvanse)?*

YesNo
Do you experience chronic pain (ongoing pain lasting more than 3 months)?*

YesNo
Hormone and Breast Health History
Are you still having menstrual cycles?*

YesNoIrregularPostmenopausal (>1 year without a period)
Have you ever been diagnosed with polycystic ovary syndrome (PCOS)?**

YesNo
Are you currently using any form of hormonal birth control? (Examples: birth control pill, hormonal IUD, implant, patch, injection, ring)*

YesNo
If yes, please specify type/brand and how long you have been using it.
Have you had a hysterectomy?*

NoYes - full hysterectomyYes - partial hysterectomyYes - unsure which hysterectomy
Have you ever used hormone therapy (including estrogen, progesterone, testosterone, DHEA, thyroid, etc.)?*

YesNo
If yes, please list type(s) and approximate dates:
Have you ever been diagnosed with breast cancer?*

YesNo
If yes, please provide details (diagnosis date, cancer type, treatment received, and current status):
Have you ever had an abnormal mammogram?*

YesNo
If yes, please describe and include approximate date(s):
Have you had hormone-related lab work done in the past 6 months?

YesNo
Upload your most recent labs (PDF or photo – optional):

Browse Files

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Final Comments or Goals
Please share anything else you’d like us to know about your symptoms, health history, or goals for hormone optimization:
Should be Empty:

Female Hormone Optimization Form

Patient Information

Current Symptom Severity Rating (Past 2 Weeks)

General Health Self-Assessment

Hormone Symptom Rating

General Health Questions

Hormone and Breast Health History

Final Comments or Goals