Female Hormone Consultation History
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Past Medical History
Check the conditions that apply to you:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None of the above
Please describe any other medical problems or details of the above:
Are you currently taking any medication?
*
Yes
No
List medication/s if applicable:
Do you have any medication allergies?
*
Yes
No
Not Sure
Social History
Do you use tobacco products?
*
Please Select
Yes
No
Do you use or do you have history of using illicit drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Gynecological History
When was your last PAP smear?
Any previous abnormal PAP smears or cervical biopsies?
Yes
No
Date of last mammogram?
Any previous abnormalities of the breasts?
Yes
No
Please describe:
How old were you when your periods started?
Please describe your periods:
Duration, Flow, Regularity, Associated problems, etc.
Please indicate Past or Current Birth Control use:
Personal or Family History of any of the following cancers:
Cervical
Breast
Uterine
Colon
Please describe if applicable:
Have you received hormonal treatment before
Yes
No
Type option 1
Type option 2
Type option 3
Type option 4
Estrogen Deficiency Symptoms
Have you experienced any of these symptoms persistently over the past 2 months? Please mark the symptoms that apply:
Hot flashes
Night sweats
Vaginal Dryness
Foggy thinking
Memory lapses
Urinary incontinence
Tearful
Emotional
Depressed
Sleep disturnaces
Heart palpitations
Bone loss / Osteoporosis
Headaches
Estrogen Excess / Progesterone Deficiency Symptoms
Please indicate any of the following symptoms you may have experienced on an ongoing basis:
Mood swings
Premenstual Syndrome (PMS)
Breast tenderness
Heavy menstrual bleeding
Ovarian cysts
Water retention
Sugar cravings
Nervousness
Anxiety
Irritability
Fibrocystic breasts
Cold temperature
Weight gain
Low libido
Adrenal Function - Cortisol Deficiency
Please indicate which of the following symptoms have been bothering you:
Fatigue
Sugar cravings
Environmental allergies
Stress
Irritability
Cold body temperature
Heart palpitations
Aches and pain
Adrenal Function - Cortisol Excess
Please indicate any of the following symptoms that have bothered you recently:
Sleep problems
Fatigue
Bone loss
Weight gain
Loss of muscle mass
Thinning of the skin
Heart palpitations
Stress
Low libido
Acne
Nervousness / Anxiety
Increased body or facial hair
Thyroid Under Activity
Pleas indicate if you have any of the following symptoms:
Cold body temperature
Constipation
Weight gain
Hair loss
Dry skin
Stress
Irritabiliry
Lack of motivation
Muscle cramps
Aches and pains
Thyroid Over Activity
Please indicate any of the following you are experiencing:
Heat intolerance
Weight loss
Nervousness
Anxiety
Hoarseness of the voice
Eye problems
Leg swelling
Diarrhea
Tremors
Shakiness
Infertility
Coarse dry skin
General Questions
What would you like to achieve by seeing the physician?
Any comments or things you would like me to address in our consultation?
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