One Year (Follow Up) BHRT Evaluation

CONFIDENTIAL FEMALE HORMONE EVALUATION
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Format: (000) 000-0000.
Email*
example@example.com
Have there been any major changes to your health or medical history since your last consultation?
If yes, please describe any new diagnoses, surgeries, hospitalizations, or changes in medications or chronic conditions that have occurred in the past year.
Symptom Assessment

Using the following multiple choice questions below, please select all options that apply (when symptoms occur and/or the severity of symptom)
Ocuring in the Morning (AM)Ocuring MiddayOcurring in the Evening (PM)Occuring ALL DAY
Intensity of each time of day (label each time of day as mild, moderate, or severe)*
Intensity of each time of day (label each time of day as mild, moderate, or severe)*
Intensity of each time of day (label each time of day as mild, moderate, or severe)*
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Night Sweat Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Vaginal Dryness Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Incontinence Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Bleeding Changes:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Weight Gain Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Fluid Retention Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Dry Skin / Hair Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Hair Loss Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Anxiety Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Depression Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Mood Swings:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Irritability Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Headaches:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Breast Tenderness:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Cramps:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Difficulty in Falling Asleep:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Difficulty in Staying Asleep:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Fatigue:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Loss of Memory:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Foggy Thinking Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Acne Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Arthritis Symptoms:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Sex Drive:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Difficulty to Reach Climax:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Stress:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Sugar Cravings:
AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Facial and/or Body Hair:
Other Symptoms:
What’s going well with your health so far?
Questions for your upcoming appointment:
Payment
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Follow-Up / Progress Check
This up to 30-minute consultation is designed to assess your progress, review any changes in symptoms, and adjust your treatment plan as needed. Using your latest medical history and lab results, I will ensure your therapy remains aligned with your health goals, optimizing your hormone balance, energy, and overall well-being.

$100.00

Total

$0.00
BHRT Informed Consent & Continued Participation

By signing below, I confirm that I understand this is an elective, personalized treatment plan guided by Kelley and the Good Day Pharmacy team. I acknowledge that BHRT involves both potential benefits and risks, and that results may vary. I agree to follow the recommended plan, continue routine medical care with my primary provider, report any concerns, and accept financial responsibility for services not covered by insurance. I consent to secure communication about my care and understand this does not replace physician oversight. I have had my questions answered and wish to continue BHRT treatment under this guidance.
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CONFIDENTIAL FEMALE HORMONE EVALUATION

Symptom Assessment

Payment