Female Hormone Therapy form - Injection Therapy

Menstural History

Procedure Description

Hormone therapy involves administration of prescribed hormones via intramuscular or subcutaneous injection.

Expected Benefits

Possible benefits may include improved energy, mood, libido, metabolism, focus, and symptom relief. Results vary and are not guaranteed. 

Risks and possible side effects

Risks may include but not limited to, injection site pain, bruising, bleeding, infection, allergic reaction, acne, hair changes, mood changes, fluid retention, blood pressure changes, and hormone imbalance. 

Alternatives

Alternatives include oral medications, topical therapy, pellet therapy, patches, or choosing no treatment

Follow-Up & Labs

Lab monitoring and follow-up appointments are required and are the patient's responsibility. 

Self Adminsitration

If instructed on self-administration, I understand proper technique, storage, and disposal of supplies and accept responsibility.

Consent

I acknowledge that I have read and understand this information and voluntarily consent to hormone injection therapy.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONSWHATSOEVER CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK THE STAFF NOW BEFORE SIGNING THIS CONSENT FORM.

HIPAA Authorization and Acknowledgement for Open Setting Communication

As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present. 

To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:

Acknowledgement of an open setting environment

I understand that:

- Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area. 

- Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.

- I am not required to have any personal health discussions in an open setting. 

Client Rights

- I understand that I may change my preference at any time by informing a staff member. 

- I understand that my choice will not affect my care or access to services in any way. 

PROVIDER ONLY DOCUMENTATION BELOW

The client is a female presenting for evaluation and management of hormone imbalance.

The patient reports fatigue, low energy, decreased libido, mood changes, irritability, brain fog, poor sleep, hot flashes or night sweats, weight gain, decreased muscle mass, hair thinning, vaginal dryness, and sexual dysfunction.

Constitutional: Reports fatigue and decreased energy. Denies fever or chills. Cardiovascular: Denies chest pain, palpitations, syncope, or history of blood clots. Respiratory: Denies shortness of breath or cough. Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel habits. Genitourinary: Reports vaginal dryness and decreased libido. Denies dysuria or hematuria. Neurologic: Reports brain fog. Denies focal weakness, dizziness, or headaches. Psychiatric: Reports mood changes. Denies suicidal or

General: Well-appearing female in no acute distress. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Lungs clear to auscultation bilaterally without wheezes, rales, or rhonchi. Abdomen: Soft, non-tender, non-distended, no organomegaly. Neurologic: Alert and oriented x3, cranial nerves II-XII grossly intact. Skin: Warm, dry, intact without rash.

Female patient with symptoms consistent with hormone imbalance. Symptoms, medical history, and risk factors were reviewed. Patient is an appropriate candidate for hormone therapy pending laboratory evaluation. Risks, benefits, alternatives, and expectations of hormone therapy were discussed in detail, including black box warnings and potential adverse effects. Patient verbalized understanding and wishes to proceed. Laboratory evaluation will be obtained prior to medication therapy. Based on clinical symptoms, body composition, and anticipated response, the patient is anticipated to require testosterone therapy in the range of 75-150 mg, with or without adjunct estradiol pellet therapy depending on laboratory results and symptom profile. Final dosing will be individualized after lab review.

Medication adminsitration will be scheduled following review of laboratory results and medical clearance. Post-procedure care and expectations were reviewed. Patient will receive a phone or telehealth follow-up approximately 4-6 weeks after insertion to assess symptom response and screen for adverse effects. Repeat hormone labs will be obtained approximately 6-8 weeks post-insertion or sooner if clinically indicated.

RED FLAGS & CONTRAINDICATION SCREENING

The patient denies a history of breast cancer, estrogen-dependent malignancy, unexplained vaginal bleeding, active or prior venous thromboembolism, stroke, myocardial infarction, severe liver disease, uncontrolled hypertension, or known clotting disorders. The patient denies current pregnancy or breastfeeding.

BLACK BOX WARNINGS & RISK DISCUSSION

Black box warnings related to hormone therapy were reviewed, including potential increased risks of thromboembolic events, cardiovascular events, stroke, breast cancer, and endometrial cancer depending on formulation and patient risk factors. The patient verbalized understanding that hormone therapy is elective, individualized, and requires ongoing monitoring.

ICD-10 codes:

Primary: Z79.890 - Hormone Replacement Therapy Secondary: R53.83 - Other Fatigue I R68.82 - Decreased Libido I N95.1 - Menopausal

Provider Name: Stacy Sims, FNP-C

NPI: 149-733-0724