Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Hormone Replacement Therapy Questionnaire Enter Your Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Date of Birth *Phone # *Age *Occupation *Marital Status *MarriedDivorcedWidowLiving with PartnerSingleEmergency Contact: *Health and Background Information Primary Care Physician *OBGYN Physician *May we share clinical information with your PCP/OBGYN? *--- Select Choice ---YesNoMenstrual & Reproductive History Age at First Period *Date of Last Period *Are Your Periods: *--- Select Choice ---RegularIrregularAbsentHave you reached menopause? *--- Select Choice ---NoPerimenopauseYesNumber of Pregnancies?Number of Live Births?If Yes to Menopause, Age:History of:MiscarriagesIVF/Fertility TreatmentsCurrent SymptomsHot FlashesNight SweatsVaginal DrynessLow LibidoMood SwingsAnxiety/DepressionFatigueWeight GainSleep DisturbancesBrain FogHair ThinningOther SymptomsGoals for TherapySymptom ReliefEnergy LevelsSexual HealthBone HealthMood StablizationOther GoalsHave you used hormone replacement therapy before? *--- Select Choice ---YesNoIf Yes, Types used:EstrogenProgesteroneTestosteroneBioidentical hormonesIf Yes, Methods:OralPatchCream/GelInjectionPellet irritable sweats Other If Yes, Duration of Use:If Yes, Reason For Stopping:Previously had an allergic reaction to hormones or pellets?Medical History (check all that apply)Hight Blood PressureHeart DiseaseStrokeBlood Clots (DVT/PE)Breast CancerOvarian CancerUterine CancerOsteoporosisThyroid DisorderLiver DiseaseMigrainesDiabetesAutoimmune DisordersMental Health ConditionOther Medical History not Listed above?Surgical HistoryHigh Risk Past Medical/Surgical History:Breast CancerUterine CancerOvarian CancerCurrent Medications & SupplimentsSmoking Status *--- Select Choice ---NeverFormerCurrentList any Allergies/Intolerances *Are you pregnant or breast feeding? Have unexplained vaginal bleeding?Family History List chronic illnesses for family members listed below (example: high blood pressure, high cholesterol, diabetes, cancer, bleeding disorders, autoimmune diseases, etc.) MotherFatherSiblingsGrandmotherGrandfatherLifestyle & Social History SmokingNeverFormerCurrentAlcoholNoneOccasionalRegularExerciseNoneLightModerateHeavyDietBalancedVegetarian/VeganOtherIf Other, ExplainSexual Health Currently Sexually Active YesNoPain with IntercourseYesNoContraception MethodHow would you rate the stress in your life, 10 being the highest? Selected Value: 1 How do you cope with stress? *Any other questions or items you would like to discuss? *Questionnaire About Symptoms Of Hormone Deficiency You have vaginal drynessNever (0)Average (1)Poor (2)Terrible (3)You have more wrinkles than the average person your ageNever (0)Average (1)Poor (2)Terrible (3)You notice a decrease in breast sizeNever (0)Average (1)Poor (2)Terrible (3)You have droopy and sagging breastsNever (0)Average (1)Poor (2)Terrible (3)You have hot flashes or night sweatsNever (0)1-2 per day (1)8-10 per day (2)More than 10 per day (3)You have osteopenia or osteoporosisNever (0)Average (1)Poor (2)Terrible (3)Your painful intercourseNever (0)Average (1)Poor (2)Terrible (3)You are moody and irritableNever (0)Average (1)Poor (2)Terrible (3)You have decreased sex driveNever (0)Average (1)Poor (2)Terrible (3)You have decreased memoryNever (0)Average (1)Poor (2)Terrible (3)You have frequent urinary tract infectionsNever (0)Average (1)Poor (2)Terrible (3)Your menstrual periods are irregularNever (0)Average (1)Poor (2)Terrible (3)Less than 6 points - it is not likely that you have hormone deficiency 7-16 points - mild hormone deficiency 17-26 points - moderate hormone deficiency Above 27 points - severe hormone deficiency Consent & AcknowledgementI understand that hormone replacement therapy has potential risks and benefits.I confirm that the information provided is accurate.Signature of Patient / Responsible Person (type your name)DateSubmit
