Hormone Replacement Consultation Form

Hormone Replacement Consultation Form

Dandurand/Hart Pharmacies
Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth
Do you have a prescriber that is willing to prescribe hormone replacement therapy?
Who is your prescriber?
Prescriber Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you currently use Dandurand or Hart Pharmacies for your prescription needs?
Select Dandurand/Hart Pharmacy location you pick up prescriptions. Please select from dropdown menu.
Select the location you pick up your medications.
Select Dandurand/Hart Location you would like to pick up compounded hormone replacement medications. Please select from the dropdown menu.
Lifestyle/Health Information
Height and Weight?
Do you exercise?
How often?
Do you smoke?
How much do you smoke daily?
Do you consume alcohol?
How often?
Do you drink caffeinated beverages?
How many caffeinated beverages do you consume daily? Include time of day.
Are you still having menstrual cycles?
How often do you cycle?
Date of last period?
Do you have severe PMS symptoms?
Is there any chance you are pregnant?
Have you had an endometrial ablation?
Have you had a hysterectomy?
What type of hysterectomy (full or partial)? What year did hysterectomy take place?
Do you have any self or family history of the following?
Medication History
List all medications, prescription and OTC, that you take. Include doses and frequency. If you don't take any medications regularly type none. (eg. Metoprolol 25mg twice daily).
Medications continued...
Have you taken hormone replacement therapy (HRT) before?
What are you currently taking or have taken in the past?
Symptom Evaluation:

Please rank symptoms on a scale of 1 to 10...1 being minor and 10 severe.

Rows	1	2	3	4	5	6	7	8	9	10
Hot Flashes
Night Sweats
Vaginal Dryness
Arthritis
Brain Fog
Bladder Symptoms
Dry Skin
Fluid Retention
Weight Gain
Breast Tenderness
Headaches
Sleep Disruptions
Mood Swings and Irritability
Depression
Hair Loss
Fatigue
Decrease Sex Drive
Harder to Reach Climax
Cold Hands and Feet

What are your top 3 goals or symptoms you would like addressed with hormone replacement therapy?
If you haven't already scheduled your consult with our HRT consulting pharmacist, please click the link below.

Click Here to Schedule your Consult
Should be Empty:

Hormone Replacement Consultation Form

Personal Information

Lifestyle/Health Information

Medication History

Symptom Evaluation: