Natural Hormone Replacement Confidential Evaluation

From a clinical management point of view, it is very useful to gain a detailed history of possible hormone deficiencies. The answers provided in the questions below will allow the pharmacist to maintain your medical history and will help in advising about current medical therapies. All information provided will be kept confidential.
Date Date / MM / DD YYYY
Name Name First Last
Age
Birth Date Birth Date / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Occupation
Occupation Status

Occupation Status Full-time Part-time Retired Unemployed Other
Phone Day
Phone Evening
Living Situation
Status
How did you hear about Natural Hormone Replacement Therapy
If you had a referral, who referred you?
Have you discussed HRT with your Health Care Practitioner?
Do you understand what Natural Hormone Replacement is?
What are your three main symptoms/Concerns?
Since When?
Medical Status:
Primary Health Care Practitioner/Physician
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Physicians Currently Seeing:
General Health:

General Health: Excellent Good Fair Poor
Height
Weight
Allergies
Blood Type
Current Diagnosis or Medical Conditions
Current Medications
Current Vitamins or OTC products: (Please list ALL, May bring in products at time evaluation)
Current Herbs/etc.
Are you currently on Natural Progesterone cream?

Are you currently on Natural Progesterone cream? Yes No
If yes, brand name
How long have you been on Progesterone cream
How much are you using and when
Current Hormone Replacement Therapy: Name
Current Hormone Replacement Therapy: Strength
Date started:
How and when do you take current HRT?
Previous Hormone Replacement Therapy: Name
Previous Hormone Replacement Therapy: Strength
Reason For Change
Any lab results you may wish to enclose would be helpful for your evaluation.
FSH
PROGESTERONE
ESTRIOL (E3)
ESTRADIOL (E2)
ESTR0NE (E1)
TESTOSTERONE
TOTAL
FREE
DHEA SULFATE
CHOLESTEROL
TRIGLYCERIDES
TOTAL
HDL
LDL
Bone Density
Date
Type

Type Back Hip
T-Score
Have you ever had a mammogram
Date
Results
Have you ever had your Thyroid tested
Date
TSH:
T4
Free T3
Other
CURRENT AND PAST MEDICAL CONDITIONS
Heart Disease

Heart Disease Yes No
Date of Diagnosis
Stroke

Stroke Yes No
Date of Diagnosis
Clotting Defects

Clotting Defects Yes No
Date of Diagnosis
Kidney Trouble

Kidney Trouble Yes No
Date of Diagnosis
Fractures

Fractures Yes No
Date of Diagnosis
Colitis

Colitis Yes No
Date of Diagnosis
Irritable Bowel

Irritable Bowel Yes No
Date of Diagnosis
Ulcers

Ulcers Yes No
Date of Diagnosis
Fibromyalgia

Fibromyalgia Yes No
Date of Diagnosis
Chronic Fatique

Chronic Fatique Yes No
Date of Diagnosis
Eating Disorder

Eating Disorder Yes No
Date of Diagnosis
High Blood Pressure

High Blood Pressure Yes No
Date of Diagnosis
Varicose Veins

Varicose Veins Yes No
Date of Diagnosis
Diabetes

Diabetes Yes No
Date of Diagnosis
Epilepsy

Epilepsy Yes No
Date of Diagnosis
Arthritis

Arthritis Yes No
Date of Diagnosis
Gallbladder trouble

Gallbladder trouble Yes No
Date of Diagnosis
Asthma

Asthma Yes No
Date of Diagnosis
Autoimmune Disorder

Autoimmune Disorder Yes No
Date of Diagnosis
Osteoporosis

Osteoporosis Yes No
Date of Diagnosis
Cancer

Cancer Yes No
Date of Diagnosis
HABITS
Dietary Restrictions
Meal Choices: Breakfast
Meal Choices: Lunch
Meal Choices: Dinner
Do you get routine exercise

Do you get routine exercise Yes No
What type
How often
Do you use tobacco products
How Much
How Long
Do you use alcohol products
How Much
How Long
Do you use caffeine products?
How Much
How Long
Family History
Mother: Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Father: Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Brother(s): Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Sister(s): Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Aunt(s): Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Uncle(s): Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Paternal Grandma: Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Paternal Grandpa: Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Maternal Grandma: Important Diseases
Living/Deceased

Living/Deceased Living Deceased
Maternal Grandpa: Important Diseases
Living/Deceased

Living/Deceased Living Deceased
GYNECOLOGICAL HISTORY
Age at first period
Date of last period
Date of last pelvic exam
and Pap smear
Results
Have you ever had an abnormal pap

Have you ever had an abnormal pap Yes No
When?
How many times?
Treatment
Are you sexually active?

Are you sexually active? Yes No
Are you trying to get pregnant?

Are you trying to get pregnant? Yes No
Current birth control method
How Long
Problem with it
How Long
Past birth control and related problems
Have you ever been on birth control

Have you ever been on birth control Yes No
Brand
How long on?
Side Effects?
PLEASE FILL OUT NEXT SECTION EVEN IF NOT CYCLING NOW
How many days from start of one period to the start of next
Number of days of flow
Amount of bleeding
Amount of cramping
Premenstrual symptoms
Starting and ending when
Any current changes in your normal cycle
Any bleeding between periods
When
Any pelvic pain, pressure or fullness?
Describe
Any unusual vaginal discharge or itching?
Describe
Treatment
Age at first pregnancy
How many full term pregnancies?
Problems
Any interrupted pregnancies: Miscarriages

Any interrupted pregnancies: Miscarriages Yes No
Any interrupted pregnancies: Abortions

Any interrupted pregnancies: Abortions Yes No
Which pregnancy?
How far along?
Have you had a tubal ligation?

Have you had a tubal ligation? Yes No
When?
Cycle or symptoms change after?
Have you had a hysterectomy?

Have you had a hysterectomy? Yes No
When?
Why?
Symptoms change after hysterectomy?
Have you had any part or whole ovary removed?

Have you had any part or whole ovary removed? Yes No
When?
Why?
Symptoms change after?
Age mother in menopause?
SYMPTOMS LIST

Each Category is divided into hormone deficiency and excess, as each has a different subset of symptoms. Score the symptoms which apply to you O(none), 1 (mild), 2 (Moderate) or 3 (severe).

Estrogen Deficiency
Estrogen Deficiency	0	1	2	3
Hot Flashes	Hot Flashes0	Hot Flashes1	Hot Flashes2	Hot Flashes3
Night Sweats	Night Sweats0	Night Sweats1	Night Sweats2	Night Sweats3
Vaginal Dryness	Vaginal Dryness0	Vaginal Dryness1	Vaginal Dryness2	Vaginal Dryness3
Foggy Thinking	Foggy Thinking0	Foggy Thinking1	Foggy Thinking2	Foggy Thinking3
Memory Lapses	Memory Lapses0	Memory Lapses1	Memory Lapses2	Memory Lapses3
Incontinence	Incontinence0	Incontinence1	Incontinence2	Incontinence3
Tearful	Tearful0	Tearful1	Tearful2	Tearful3
Bone Loss	Bone Loss0	Bone Loss1	Bone Loss2	Bone Loss3
Heart Palpitations	Heart Palpitations0	Heart Palpitations1	Heart Palpitations2	Heart Palpitations3
Dry Skin/Hair	Dry Skin/Hair0	Dry Skin/Hair1	Dry Skin/Hair2	Dry Skin/Hair3
Headaches	Headaches0	Headaches1	Headaches2	Headaches3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3
Depressed	Depressed0	Depressed1	Depressed2	Depressed3

Estrogen Excess
Estrogen Excess	0	1	2	3
Mood Swings(PMS)	Mood Swings(PMS)0	Mood Swings(PMS)1	Mood Swings(PMS)2	Mood Swings(PMS)3
Tender Breast	Tender Breast0	Tender Breast1	Tender Breast2	Tender Breast3
Water Retention	Water Retention0	Water Retention1	Water Retention2	Water Retention3
Nervous	Nervous0	Nervous1	Nervous2	Nervous3
Irritable	Irritable0	Irritable1	Irritable2	Irritable3
Anxious	Anxious0	Anxious1	Anxious2	Anxious3
Fibrocystic Breast	Fibrocystic Breast0	Fibrocystic Breast1	Fibrocystic Breast2	Fibrocystic Breast3
Uterine Fibroids	Uterine Fibroids0	Uterine Fibroids1	Uterine Fibroids2	Uterine Fibroids3
Weight Gain in Hips	Weight Gain in Hips0	Weight Gain in Hips1	Weight Gain in Hips2	Weight Gain in Hips3
Weight Gain in Waist	Weight Gain in Waist0	Weight Gain in Waist1	Weight Gain in Waist2	Weight Gain in Waist3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3
Elevated Triglycerides	Elevated Triglycerides0	Elevated Triglycerides1	Elevated Triglycerides2	Elevated Triglycerides3
Cystic Ovaries	Cystic Ovaries0	Cystic Ovaries1	Cystic Ovaries2	Cystic Ovaries3
Breast Cancer	Breast Cancer0	Breast Cancer1	Breast Cancer2	Breast Cancer3
Low Libido	Low Libido0	Low Libido1	Low Libido2	Low Libido3
Headaches	Headaches0	Headaches1	Headaches2	Headaches3
Bleeding Changes	Bleeding Changes0	Bleeding Changes1	Bleeding Changes2	Bleeding Changes3
Sugar Cravings	Sugar Cravings0	Sugar Cravings1	Sugar Cravings2	Sugar Cravings3
Cold Body Temperature	Cold Body Temperature0	Cold Body Temperature1	Cold Body Temperature2	Cold Body Temperature3

Progesterone Deficiency
Progesterone Deficiency	0	1	2	3
Hot Flashes	Hot Flashes0	Hot Flashes1	Hot Flashes2	Hot Flashes3
Night Sweats	Night Sweats0	Night Sweats1	Night Sweats2	Night Sweats3
Vaginal Dryness	Vaginal Dryness0	Vaginal Dryness1	Vaginal Dryness2	Vaginal Dryness3
Foggy Thinking	Foggy Thinking0	Foggy Thinking1	Foggy Thinking2	Foggy Thinking3
Memory Lapses	Memory Lapses0	Memory Lapses1	Memory Lapses2	Memory Lapses3
Incontinence	Incontinence0	Incontinence1	Incontinence2	Incontinence3
Tearful	Tearful0	Tearful1	Tearful2	Tearful3
Depressed	Depressed0	Depressed1	Depressed2	Depressed3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3
Cramps	Cramps0	Cramps1	Cramps2	Cramps3
PMS/Mood Swings	PMS/Mood Swings0	PMS/Mood Swings1	PMS/Mood Swings2	PMS/Mood Swings3
Irregular Bleeding	Irregular Bleeding0	Irregular Bleeding1	Irregular Bleeding2	Irregular Bleeding3
Break Thru Bleeding	Break Thru Bleeding0	Break Thru Bleeding1	Break Thru Bleeding2	Break Thru Bleeding3
Heavy Periods	Heavy Periods0	Heavy Periods1	Heavy Periods2	Heavy Periods3
Irritability	Irritability0	Irritability1	Irritability2	Irritability3
Water Retention	Water Retention0	Water Retention1	Water Retention2	Water Retention3
Headaches	Headaches0	Headaches1	Headaches2	Headaches3
Anxiety	Anxiety0	Anxiety1	Anxiety2	Anxiety3
Nervous	Nervous0	Nervous1	Nervous2	Nervous3
Cystic Ovaries	Cystic Ovaries0	Cystic Ovaries1	Cystic Ovaries2	Cystic Ovaries3
Heart Palpitations	Heart Palpitations0	Heart Palpitations1	Heart Palpitations2	Heart Palpitations3
Bone Loss	Bone Loss0	Bone Loss1	Bone Loss2	Bone Loss3

Progesterone Excess
Progesterone Excess	0	1	2	3
Sleeplessness	Sleeplessness0	Sleeplessness1	Sleeplessness2	Sleeplessness3
Breast Tenderness on Sides	Breast Tenderness on Sides0	Breast Tenderness on Sides1	Breast Tenderness on Sides2	Breast Tenderness on Sides3
Decreased Libido	Decreased Libido0	Decreased Libido1	Decreased Libido2	Decreased Libido3
Mild Depression	Mild Depression0	Mild Depression1	Mild Depression2	Mild Depression3
Candida Infections	Candida Infections0	Candida Infections1	Candida Infections2	Candida Infections3

Androgen Deficiency
Androgen Deficiency	0	1	2	3
Low Libido	Low Libido0	Low Libido1	Low Libido2	Low Libido3
Vaginal Dryness	Vaginal Dryness0	Vaginal Dryness1	Vaginal Dryness2	Vaginal Dryness3
Foggy Thinking	Foggy Thinking0	Foggy Thinking1	Foggy Thinking2	Foggy Thinking3
Fatigue	Fatigue0	Fatigue1	Fatigue2	Fatigue3
Aches and Pains	Aches and Pains0	Aches and Pains1	Aches and Pains2	Aches and Pains3
Memory Lapses	Memory Lapses0	Memory Lapses1	Memory Lapses2	Memory Lapses3
Incontinence	Incontinence0	Incontinence1	Incontinence2	Incontinence3
Depressed	Depressed0	Depressed1	Depressed2	Depressed3
Bone Loss	Bone Loss0	Bone Loss1	Bone Loss2	Bone Loss3
Decreased Muscle Mass	Decreased Muscle Mass0	Decreased Muscle Mass1	Decreased Muscle Mass2	Decreased Muscle Mass3
Thinning Skin	Thinning Skin0	Thinning Skin1	Thinning Skin2	Thinning Skin3
Heart Palpitations	Heart Palpitations0	Heart Palpitations1	Heart Palpitations2	Heart Palpitations3
Headaches	Headaches0	Headaches1	Headaches2	Headaches3
Fibromyalgia	Fibromyalgia0	Fibromyalgia1	Fibromyalgia2	Fibromyalgia3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3

Androgen Excess
Androgen Excess	0	1	2	3
Increased Facial Hair	Increased Facial Hair0	Increased Facial Hair1	Increased Facial Hair2	Increased Facial Hair3
Increased Body Hair	Increased Body Hair0	Increased Body Hair1	Increased Body Hair2	Increased Body Hair3
Loss of Scalp Hair	Loss of Scalp Hair0	Loss of Scalp Hair1	Loss of Scalp Hair2	Loss of Scalp Hair3
Increased Acne	Increased Acne0	Increased Acne1	Increased Acne2	Increased Acne3
Oily Skin	Oily Skin0	Oily Skin1	Oily Skin2	Oily Skin3
Irritable	Irritable0	Irritable1	Irritable2	Irritable3
Anxious	Anxious0	Anxious1	Anxious2	Anxious3
Ovarian Cyst	Ovarian Cyst0	Ovarian Cyst1	Ovarian Cyst2	Ovarian Cyst3

Cortisol Deficiency
Cortisol Deficiency	0	1	2	3
Fatigue	Fatigue0	Fatigue1	Fatigue2	Fatigue3
Sugar Craving	Sugar Craving0	Sugar Craving1	Sugar Craving2	Sugar Craving3
Allergies	Allergies0	Allergies1	Allergies2	Allergies3
Chemical Sensitivity	Chemical Sensitivity0	Chemical Sensitivity1	Chemical Sensitivity2	Chemical Sensitivity3
Stress	Stress0	Stress1	Stress2	Stress3
Cold Body Temp	Cold Body Temp0	Cold Body Temp1	Cold Body Temp2	Cold Body Temp3
Heart Palpitations	Heart Palpitations0	Heart Palpitations1	Heart Palpitations2	Heart Palpitations3
Aches and Pains	Aches and Pains0	Aches and Pains1	Aches and Pains2	Aches and Pains3
Irritable	Irritable0	Irritable1	Irritable2	Irritable3
Arthritis	Arthritis0	Arthritis1	Arthritis2	Arthritis3

Cortisol Excess
Cortisol Excess	0	1	2	3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3
Bone Loss	Bone Loss0	Bone Loss1	Bone Loss2	Bone Loss3
Fatigue	Fatigue0	Fatigue1	Fatigue2	Fatigue3
Weight Gain in Waist	Weight Gain in Waist0	Weight Gain in Waist1	Weight Gain in Waist2	Weight Gain in Waist3
Thinning Skin	Thinning Skin0	Thinning Skin1	Thinning Skin2	Thinning Skin3
Loss of Muscle Mass	Loss of Muscle Mass0	Loss of Muscle Mass1	Loss of Muscle Mass2	Loss of Muscle Mass3
Elevated Triglycerides	Elevated Triglycerides0	Elevated Triglycerides1	Elevated Triglycerides2	Elevated Triglycerides3
Irritable	Irritable0	Irritable1	Irritable2	Irritable3
Anxious	Anxious0	Anxious1	Anxious2	Anxious3
Memory Lapses	Memory Lapses0	Memory Lapses1	Memory Lapses2	Memory Lapses3
Depressed	Depressed0	Depressed1	Depressed2	Depressed3
Headaches	Headaches0	Headaches1	Headaches2	Headaches3
Stress	Stress0	Stress1	Stress2	Stress3
Sugar Cravings	Sugar Cravings0	Sugar Cravings1	Sugar Cravings2	Sugar Cravings3
Hair Loss	Hair Loss0	Hair Loss1	Hair Loss2	Hair Loss3
Low Libido	Low Libido0	Low Libido1	Low Libido2	Low Libido3
Increased Facial Hair	Increased Facial Hair0	Increased Facial Hair1	Increased Facial Hair2	Increased Facial Hair3
Increased Body Hair	Increased Body Hair0	Increased Body Hair1	Increased Body Hair2	Increased Body Hair3
Acne	Acne0	Acne1	Acne2	Acne3
Nervous	Nervous0	Nervous1	Nervous2	Nervous3

Thyroid Deficiency
Thyroid Deficiency	0	1	2	3
Tired/Exhausted	Tired/Exhausted0	Tired/Exhausted1	Tired/Exhausted2	Tired/Exhausted3
Sad or Depressed	Sad or Depressed0	Sad or Depressed1	Sad or Depressed2	Sad or Depressed3
Cold Body Temp	Cold Body Temp0	Cold Body Temp1	Cold Body Temp2	Cold Body Temp3
Cold Hands & Feet	Cold Hands & Feet0	Cold Hands & Feet1	Cold Hands & Feet2	Cold Hands & Feet3
Weight Gain	Weight Gain0	Weight Gain1	Weight Gain2	Weight Gain3
Can't Lose Weight	Can't Lose Weight0	Can't Lose Weight1	Can't Lose Weight2	Can't Lose Weight3
Memory Lapses	Memory Lapses0	Memory Lapses1	Memory Lapses2	Memory Lapses3
Forgetful	Forgetful0	Forgetful1	Forgetful2	Forgetful3
High Cholesterol	High Cholesterol0	High Cholesterol1	High Cholesterol2	High Cholesterol3
Foggy Thinking	Foggy Thinking0	Foggy Thinking1	Foggy Thinking2	Foggy Thinking3
Mood Changes	Mood Changes0	Mood Changes1	Mood Changes2	Mood Changes3
Low Blood Pressure	Low Blood Pressure0	Low Blood Pressure1	Low Blood Pressure2	Low Blood Pressure3
Slow Pulse Rate	Slow Pulse Rate0	Slow Pulse Rate1	Slow Pulse Rate2	Slow Pulse Rate3
Decreased Sweating	Decreased Sweating0	Decreased Sweating1	Decreased Sweating2	Decreased Sweating3
Slow Ankle Reflex	Slow Ankle Reflex0	Slow Ankle Reflex1	Slow Ankle Reflex2	Slow Ankle Reflex3
Hair Loss	Hair Loss0	Hair Loss1	Hair Loss2	Hair Loss3
Hair Dry or Brittle	Hair Dry or Brittle0	Hair Dry or Brittle1	Hair Dry or Brittle2	Hair Dry or Brittle3
Nails Breaking or Brittle	Nails Breaking or Brittle0	Nails Breaking or Brittle1	Nails Breaking or Brittle2	Nails Breaking or Brittle3
Aches and Pains	Aches and Pains0	Aches and Pains1	Aches and Pains2	Aches and Pains3
Low Libido	Low Libido0	Low Libido1	Low Libido2	Low Libido3
Heart Palpitations	Heart Palpitations0	Heart Palpitations1	Heart Palpitations2	Heart Palpitations3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3
Swelling/Puffy Eyes/Face	Swelling/Puffy Eyes/Face0	Swelling/Puffy Eyes/Face1	Swelling/Puffy Eyes/Face2	Swelling/Puffy Eyes/Face3
Bone Loss	Bone Loss0	Bone Loss1	Bone Loss2	Bone Loss3
Decreased Muscle Mass	Decreased Muscle Mass0	Decreased Muscle Mass1	Decreased Muscle Mass2	Decreased Muscle Mass3
Thinning Skin	Thinning Skin0	Thinning Skin1	Thinning Skin2	Thinning Skin3
Infertility Problems	Infertility Problems0	Infertility Problems1	Infertility Problems2	Infertility Problems3
Slowed Reflexes	Slowed Reflexes0	Slowed Reflexes1	Slowed Reflexes2	Slowed Reflexes3
Constipation	Constipation0	Constipation1	Constipation2	Constipation3
Hoarseness	Hoarseness0	Hoarseness1	Hoarseness2	Hoarseness3

Thyroid Excess
Thyroid Excess	0	1	2	3
Rapid Weight Loss	Rapid Weight Loss0	Rapid Weight Loss1	Rapid Weight Loss2	Rapid Weight Loss3
Insomnia	Insomnia0	Insomnia1	Insomnia2	Insomnia3
Difficulty Falling Asleep	Difficulty Falling Asleep0	Difficulty Falling Asleep1	Difficulty Falling Asleep2	Difficulty Falling Asleep3
Unusual Sweating	Unusual Sweating0	Unusual Sweating1	Unusual Sweating2	Unusual Sweating3
Always Feeling Hot	Always Feeling Hot0	Always Feeling Hot1	Always Feeling Hot2	Always Feeling Hot3
Bulging Eyes	Bulging Eyes0	Bulging Eyes1	Bulging Eyes2	Bulging Eyes3
Erratic Behavior	Erratic Behavior0	Erratic Behavior1	Erratic Behavior2	Erratic Behavior3
Anxiety	Anxiety0	Anxiety1	Anxiety2	Anxiety3
Irritability	Irritability0	Irritability1	Irritability2	Irritability3
Nervous	Nervous0	Nervous1	Nervous2	Nervous3
Panic Attacks	Panic Attacks0	Panic Attacks1	Panic Attacks2	Panic Attacks3
Decreased Concentration	Decreased Concentration0	Decreased Concentration1	Decreased Concentration2	Decreased Concentration3
Short Attention Span	Short Attention Span0	Short Attention Span1	Short Attention Span2	Short Attention Span3
Rapid Heat Beat	Rapid Heat Beat0	Rapid Heat Beat1	Rapid Heat Beat2	Rapid Heat Beat3
Goiter	Goiter0	Goiter1	Goiter2	Goiter3

IG-1 Deficiency
IG-1 Deficiency	0	1	2	3
Rapid Aging	Rapid Aging0	Rapid Aging1	Rapid Aging2	Rapid Aging3
Sleep Disturbances	Sleep Disturbances0	Sleep Disturbances1	Sleep Disturbances2	Sleep Disturbances3
Memory Impairment	Memory Impairment0	Memory Impairment1	Memory Impairment2	Memory Impairment3
Decreased Stamina	Decreased Stamina0	Decreased Stamina1	Decreased Stamina2	Decreased Stamina3
Decreased Libido	Decreased Libido0	Decreased Libido1	Decreased Libido2	Decreased Libido3
Increased Fatigue	Increased Fatigue0	Increased Fatigue1	Increased Fatigue2	Increased Fatigue3
Heart Disease	Heart Disease0	Heart Disease1	Heart Disease2	Heart Disease3
Osteoporosis	Osteoporosis0	Osteoporosis1	Osteoporosis2	Osteoporosis3
Thinning Skin	Thinning Skin0	Thinning Skin1	Thinning Skin2	Thinning Skin3
Insulin Insensitivity	Insulin Insensitivity0	Insulin Insensitivity1	Insulin Insensitivity2	Insulin Insensitivity3
Sexual Dysfunction	Sexual Dysfunction0	Sexual Dysfunction1	Sexual Dysfunction2	Sexual Dysfunction3
Central Obesity	Central Obesity0	Central Obesity1	Central Obesity2	Central Obesity3

IG-1 Excess
IG-1 Excess	0	1	2	3
Visual Field Defects	Visual Field Defects0	Visual Field Defects1	Visual Field Defects2	Visual Field Defects3
Thickening of Palms	Thickening of Palms0	Thickening of Palms1	Thickening of Palms2	Thickening of Palms3
Thickening of Heel Pads	Thickening of Heel Pads0	Thickening of Heel Pads1	Thickening of Heel Pads2	Thickening of Heel Pads3
Increased Cranial Growth	Increased Cranial Growth0	Increased Cranial Growth1	Increased Cranial Growth2	Increased Cranial Growth3
Changes in Skull/Face	Changes in Skull/Face0	Changes in Skull/Face1	Changes in Skull/Face2	Changes in Skull/Face3
Enlarged/Thickening Heart	Enlarged/Thickening Heart0	Enlarged/Thickening Heart1	Enlarged/Thickening Heart2	Enlarged/Thickening Heart3

Do you wish for us to fill out the necessary paper work to seek reimbursement for this evaluation through your insurance provider?

Do you wish for us to fill out the necessary paper work to seek reimbursement for this evaluation through your insurance provider? Yes No
If Yes, list your insurance provider
If you have a prescription filled at Central Iowa Compounding, do you wish for us to fill out the paper work necessary to seek reimbursement

If you have a prescription filled at Central Iowa Compounding, do you wish for us to fill out the paper work necessary to seek reimbursement Yes No
If yes, list your prescription insurance provider, (Please note that sometimes your prescription provider is different than your medical provider)

Natural Hormone Replacement Confidential Evaluation

Natural Hormone Replacement Confidential Evaluation

Medical Status:

Any lab results you may wish to enclose would be helpful for your evaluation.

CURRENT AND PAST MEDICAL CONDITIONS

HABITS

Family History

GYNECOLOGICAL HISTORY

PLEASE FILL OUT NEXT SECTION EVEN IF NOT CYCLING NOW

SYMPTOMS LIST