WOMEN’S HORMONE DEFICIENCY SCREENING

WOMEN’S HORMONE DEFICIENCY SCREENING – BEFORE HRT

5301 Alpha Road Suite 34, Room 21 - Dallas, TX 75240 Phone: 214-890-6180 | Fax: 1-214-241-4792 Email: contact@jaenixmedspa.com
Your Information

Please provide your personal details.
Full Name*

First NameLast Name
Email Address*
example@example.com
Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Age Range*
What are your goals for treatment? Do you have any specific concerns you would like addressed?*
Please list any medical conditions you have been diagnosed with such as high blood pressure.*
What surgeries have you had and when?*
Hospitalizations?*
Have you ever been on testosterone replacement? Please describe your history of prescribed or illicit steroid use:*
What medications and/or supplements are you currently taking?*
Please list any allergies you have to medications or supplements?*
What conditions or diseases do you know are in your family history?*
What symptoms are you currently experiencing?*
If "Other" Symptoms, Please List:
TX Driver's License # (in order to ship testosterone)*
UPLOAD PHOTO OF DRIVERS LICENSE - FRONT AND BACK PHOTO*

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Upload a copy of your most recent labs here, must be within 90 days.

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Exercise Frequency*
Are you dieting? If so, what type of diet?*
Do you consume alcohol? If yes, please describe your alcohol intake:*
Do you use tobacco? If yes, how much?*
Do you use any recreational drugs? If yes, what kind and how often?*
Are you sexually active?*

YesNo
Are you currently pregnant/breastfeeding?*

YesNo
Are you trying to get pregnant in the future?*

YesNo
Do you experience painful intercourse*

YesNo
Please describe your family health history. Please include conditions such as prostate cancer, heart attacks, stroke, diabetes, high blood pressure etc. Please also include their age or if they are deceased.*
Father
Mother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Siblings
Children
Do you have any issues with anxiety?*

YesNo
Do you feel depressed?*

YesNo
Do you have problems with eating or your appetite?*

YesNo
Do you experience lack of motivation?*

YesNo
Do you have trouble sleeping?*

YesNo
Date of last pap smear:

MonthDayYear
Date
Have you had a prior hysterectomy? Total/Partial?*

TotalPartialNo
General Consent for Evaluation and Treatment
Hormone Replacement Therapy (HRT/BHRT) Consent

MRS Symptom Checklist*

Rows	None	Mild	Moderate	Severe	Extremely Severe
1. Hot flashes, sweating (episodes of sweating)
2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
5. Irritability (feeling nervous, inner tension, feeling aggressive)
6. Anxiety (inner restlessness, feeling panicky)
7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
8. Sexual problems (change in sexual desire, in sexual activity and satisfaction)
9. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)

Do you have cold hands and feet?*

YesNo
Do you have daily bowel movements?*

YesNo
Do you have gas, bloating, or abdominal pain after eating?*

YesNo
Please select your WEEKLY Activity Level (Physical activity that accelerates heart rate or causes breathlessness)*

0-1 day per week (Low)2-3 days per week (Average)More than 3 days per week (High)
Please list any prior hormone therapy:
Please share any additional comments about your symptoms you would like to address.
Should be Empty:

WOMEN’S HORMONE DEFICIENCY SCREENING – BEFORE HRT

Your Information