FEMALE HORMONE QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential.
CONTACT & PERSONAL INFORMATION
Please review our policies on making recommendations in the "Getting Started" section located in the Resources tab on our website.
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
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Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
example@example.com
Height (in):
Weight (lbs):
PHONE NUMBER(S)
Home:
Format: (000) 000-0000.
Mobile:
Format: (000) 000-0000.
ALLERGIES TO MEDICATIONS OR FOODS (DRUG/FOOD NAME & REACTION EXPERIENCED)
INSURANCE INFORMATION
Do you have prescription drug insurance?
Yes
No
Insurance Company:
Insurance ID#:
Rx Group #:
Rx Bin #:
Rx PCN:
Is the patient the primary cardholder, spouse, or dependent?
Doctor's Name:
Doctor's Office Fax number
Format: (000) 000-0000.
WHAT ARE YOUR MAIN REASONS FOR SEEKING CARE?
LIST YOUR PRESCRIBED DRUGS AND OVER-THE-COUNTER DRUGS, SUCH AS VITAMINS, NUTRITIONAL OR NATURAL PRODUCTS YOU ARE CURRENTLY TAKING
LIST ANY PREVIOUS HORMONE THERAPY YOU HAVE TRIED
WHICH OF THE FOLLOWING HORMONE-RELATED TREATMENTS HAVE YOU USED IN THE PAST OR CURRENTLY USING? PLEASE SPECIFY IF APPLICABLE.
Hormonal IUD
Non-Hormonal IUD
Birth control tablets
Hormonal patches (e.g. Xulane, Vivelle Dot, Estradiol)
Vaginal ring (e.g. Nuvaring)
Hormonal pellets
Hormone creams or gels
Hormone capsules
Hormone injections (e.g. Estrogen, Depo Provera, Testosterone)
Bioidentical hormone therapy
None of the above
Other
SURGERY AND MEDICAL HISTORY All questions contained in this questionnaire are optional and will be kept strictly confidential.
HYSTERECTOMY DATE (IF APPLICABLE)
-
Month
-
Day
Year
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TUBAL LIGATION (IF APPLICABLE)
-
Month
-
Day
Year
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OVARY REMOVAL DATE (IF APPLICABLE)
-
Month
-
Day
Year
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ABLATION DATE (IF APPLICABLE)
-
Month
-
Day
Year
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MASTECTOMY (SINGLE OR DOUBLE) (IF APPLICABLE)
-
Month
-
Day
Year
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CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD PREVIOUSLY OR CURRENTLY
Thyroid disease
High cholesterol
Osteoporosis
Blood clotting disorder
Lupus/Fibromyalgia/ Autoimmune disease
Fibrocystic breast disease
Heart disease
Cancer
High blood pressure
Type 2 Diabetes
Endometriosis
Stroke
Type 1 Diabetes
Headaches/Migraines
Other
IS THERE A FAMILY HISTORY OF..?
Uterine cancer
Osteoporosis
Breast cancer
Ovarian cancer
Heart disease
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IF YOU HAVE A FAMILY HISTORY OF ABOVE, WHAT'S THEIR RELATION TO YOU?
DO YOU STILL HAVE YOUR PERIOD?
Yes
No
IF YOU STILL HAVE REGULAR PERIODS, WHAT WAS THE DATE OF YOUR LAST PERIOD?
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Month
-
Day
Year
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HAVE YOU HAD A MAMMOGRAM?
Yes
No
(IF YES) WITHIN THE LAST 12 MONTHS, WHEN WAS THE DATE? (IF YOU HAVE NOT HAD A MAMMOGRAM AND NEED TO BYPASS THIS QUESTION, PLEASE INDICATE FIELD WITH DATE OF 01/01/1900.)
-
Month
-
Day
Year
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HAVE YOU HAD A BONE DENSITY TEST WITHIN THE LAST 3 YEARS?
Yes
No
DO YOU OR DID YOU HAVE PMS OR PMDD?
Yes
No
RATE THE FOLLOWING IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS RECENTLY
Rows
O None
1 Mild
3 Moderate
4 Severe
Sleep disruption/Insomnia
Decreased libido (sex drive)
Night sweats
Depression
Fluid retention
Vaginal drynes
Migraines/headaches
Irritability
New facial hair
Nervousness/anxiety
Decreased quality of orgasm or intercourse
Hot flashes
Breast tenderness
Dry skin
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Rows
O None
1 Mild
3 Moderate
4 Severe
Mood swings
Crying easily
Weight gain
Short term memory loss
Painful intercourse
Poor concentration
Food cravings
Backaches
Hair loss
Fatigue
Acne
Oily skin
Dry eyes
Decreased muscle mass
Bleeding changes or disorders
Heart palpitations
Brittle or breaking nails
Thinning of skin
DO YOU USE TOBACCO PRODUCTS?
Yes. If so, we will need a signed release form from your current physician before we can participate in a recommendation.
No
DO YOU GET PHYSICAL EXERCISE? IF YES, WHAT TYPE AND HOW OFTEN?
DO YOU HAVE ANY QUESTIONS/COMMENTS OR CONCERNS REGARDING NATURAL HORMONE REPLACEMENT THERAPY?
HOW DID YOU HEAR ABOUT US?
Radio
TV Channel 9
Facebook
Invitation in Mail
YouTube
TV Channel 41
Website
Other
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