Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.FORM #1 - Hormone Replacement Therapy Questionnaire Enter Your Name * HRT? decreased reaction 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 # *Health and Background Information Age *Gender: Female Occupation *Smoking Status *--- Select Choice ---NeverFormerCurrentList and Health Problems or Physical Limitations *List any Allergies/Intolerances *Have you ever had any hormone sensitive cancer such as breast or prostrate cancer?Have you ever had blood clots or heart disease?Have you ever had liver disease?Are you pregnant or breast feeding? Have unexplained vaginal bleeding?Previously had an allergic reaction to hormones or pellets?How would you rate the stress in your life, 10 being the highest? Selected Value: 1 How do you cope with stress? *What are your goals with HRT? *What part of your life do you want to improve the most? *Have you tried HRT in the past? *YesNoAny other questions or items you would like to discuss? *FORM #2 - Questionnaire About Symptoms Of Hormone Deficiency Enter Your Name AgainYou 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 Signature of Patient / Responsible Person (type your name)DateSubmit
