Women's Consultation Form

Date Date / MM / DD YYYY
Select a location
Personal Information
Name Name First Last
Birthdate Birthdate / MM / DD YYYY
Age
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Email
Gender

Gender Male Female
Height
Weight
Previous Dr.'s Name
Previous Dr.'s Address Previous Dr.'s Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Previous Dr.'s Phone Previous Dr.'s Phone - ### - ### ####
Previous Dr.'s Name
Previous Dr.'s Address Previous Dr.'s Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Previous Dr.'s Phone Previous Dr.'s Phone - ### - ### ####
Previous Dr.'s Name
Previous Dr.'s Address Previous Dr.'s Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Previous Dr.'s Phone Previous Dr.'s Phone - ### - ### ####
Medical Conditions/Diseases: Please check all that apply to you.

Medical Conditions/Diseases: Please check all that apply to you. Thyroid disease Hormonal Related Issues Other: Please list Other: Please list
List Hormones Previously Taken
Hormone 1
Date Hormone 1 Started
Date Hormone 1 Stopped
Reason
Hormone 2
Date Hormone 2 Started
Date Hormone 2 Stopped
Reason
Hormone 3
Date Hormone 3 Started
Date Hormone 3 Stopped
Reason
Any additional hormones here
Have you had a tubal ligation?

Have you had a tubal ligation? No Yes
Date of procedure?

Please answer the following questions:
Please answer the following questions:	Absent	Mild	Moderate	Severe
Fibrocystic Breast	Fibrocystic BreastAbsent	Fibrocystic BreastMild	Fibrocystic BreastModerate	Fibrocystic BreastSevere
Weight Gain	Weight GainAbsent	Weight GainMild	Weight GainModerate	Weight GainSevere
Heavy/Irregular menses	Heavy/Irregular mensesAbsent	Heavy/Irregular mensesMild	Heavy/Irregular mensesModerate	Heavy/Irregular mensesSevere
Hot Flashes	Hot FlashesAbsent	Hot FlashesMild	Hot FlashesModerate	Hot FlashesSevere
Headaches	HeadachesAbsent	HeadachesMild	HeadachesModerate	HeadachesSevere
Irritability	IrritabilityAbsent	IrritabilityMild	IrritabilityModerate	IrritabilitySevere
Mood Swings	Mood SwingsAbsent	Mood SwingsMild	Mood SwingsModerate	Mood SwingsSevere
Breast Tenderness	Breast TendernessAbsent	Breast TendernessMild	Breast TendernessModerate	Breast TendernessSevere
Sleep Disturbances/Insomnia	Sleep Disturbances/InsomniaAbsent	Sleep Disturbances/InsomniaMild	Sleep Disturbances/InsomniaModerate	Sleep Disturbances/InsomniaSevere
Cramps	CrampsAbsent	CrampsMild	CrampsModerate	CrampsSevere
Fatigue	FatigueAbsent	FatigueMild	FatigueModerate	FatigueSevere
Loss of Memory	Loss of MemoryAbsent	Loss of MemoryMild	Loss of MemoryModerate	Loss of MemorySevere
Bladder Symptoms	Bladder SymptomsAbsent	Bladder SymptomsMild	Bladder SymptomsModerate	Bladder SymptomsSevere
Arthritis	ArthritisAbsent	ArthritisMild	ArthritisModerate	ArthritisSevere
Harder to Reach Climax	Harder to Reach ClimaxAbsent	Harder to Reach ClimaxMild	Harder to Reach ClimaxModerate	Harder to Reach ClimaxSevere
Decreased Sex Drive	Decreased Sex DriveAbsent	Decreased Sex DriveMild	Decreased Sex DriveModerate	Decreased Sex DriveSevere
Hair Loss	Hair LossAbsent	Hair LossMild	Hair LossModerate	Hair LossSevere

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy? Doctor Self Friend/Family Member Other Other
What are your goals with taking Bio-Identical Hormone Replacement?
Please write down any questions you have about Bio-Identical Hormone Replacement Therapy.

Women's Consultation Form

Women's Consultation Form

Personal Information

List Hormones Previously Taken