Confidential Female Hormone Evaluation

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Name Name * First Last
Birth Date Birth Date / MM / DD YYYY
Age
Maximum of 3 characters allowed. Currently Entered: 0 characters.
Address
City
State
Zip
Phone (Primary) *
Phone (Secondary)
Email *
Height
Weight
Your Occupation
Practitioner(s) currently seeing
Practitioner Name Practitioner Name First Last
Practitioner Address
Practitioner Phone
Practitioner Name Practitioner Name First Last
Practitioner Address
Practitioner Phone
Practitioner Name Practitioner Name First Last
Practitioner Address
Practitioner Phone
How did you arrive at the decision to consider BHRT?

How did you arrive at the decision to consider BHRT? Doctor Self Friend/Family Member Other Other
Who Referred You?
Current Medical Conditions:
Allergies: Please check all that apply

Allergies: Please check all that apply Penicillin Morphine Dye Allergies Pet Allergies Codeine Aspirin Nitrate Allergy Seasonal Allergies Sulfa Drug Food Allergies No Known Allergies
List additional Allergies
Please describe the allergic reaction you experienced and when it occurred.
Over the counter (OTC) medications

Please check all products that you use occasionally or regularly. Check all that apply.

Over the counter (OTC) medications

Please check all products that you use occasionally or regularly. Check all that apply.

Pain reliever Sleep aids Aspirin Anti-diarrheals Acetaminophen (example Tylenol®) Laxatives Ibuprofen (example Motrin®, Advil®) Diet Aids/Weight Loss products Naproxen (example Aleve®) Antacids Ketoprofen (example Orudis KT®) Acid blockers Cough Suppressant (example Robitussin DM®) Antihistamine product (Benedryl®) Decongestant product (Sudafed®)
List additional Over the counter (OTC) medications
Nutritional/Natural Supplements:

Please list the products you are using
Vitamins
Minerals
Herbs
Enzymes
Nutritional/Protein Supplements
List additional Nutritional/Natural Supplements you are currently taking
Current Prescription Medications
Medication Name
Strength
Date Started
How often per day
Medication Name
Strength
Date Started
How often per day
Medication Name
Strength
Date Started
How often per day
Medication Name
Strength
Date Started
How often per day
Hormone
Date Started/Date Stopped ---> Reason
List additional Current Prescription Medications
List Hormones previously taken
Hormone
Date Started/Date Stopped ---> Reason
Hormone
Date Started/Date Stopped ---> Reason
List additional Hormones previously taken
Does anybody else in your household use hormones?

Does anybody else in your household use hormones? Yes No
Have you ever used oral contraceptives?

Have you ever used oral contraceptives? Yes No
Current form of birth control
Any problems?

Any problems? Yes No
If YES, describe any problem(s)
Habits
Dietary restrictions
Meal Choices: Breakfast
Meal Choices: Lunch
Meal Choices: Dinner
Do you use tobacco?

Do you use tobacco? Yes No
How often and how much?
Do you use alcohol?

Do you use alcohol? Yes No
How often and how much?
Do you use caffeine?

Do you use caffeine? Yes No
How often and how much?
Do you get regular exercise?

Do you get regular exercise? Yes No
What type and how often?
How many ounces of water do you drink in a day?
How often do you have a bowel movement?
Are you fearful of anything?
Rank your stress level on a typical day (0-none, 1-mild, 2-moderate, 3-severe)
List any major stressors or stressful events in the last 3 to 5 years
Medical History
Medical conditions/diseases
Please check all that apply to you.

Medical conditions/diseases
Please check all that apply to you. Heart Disease High Blood Pressure Chronic Fatigue Stroke High Cholesterol Eating Disorder Clotting Defect Diabetes Thyroid Disease Kidney Trouble Epilepsy Headaches Fractures Arthritis Cancer Colitis Gallbladder Trouble Varicose Veins Irritable Bowel Asthma
List additional Medical conditions/diseases
Age your mother went into menopause
Age your sister(s) went through menopause
When was your last period?
How many days did it last?
What is your average cycle length (i.e. 26 days, 28 days)
Breakthrough Bleeding?
Explain typical cycle (i.e. clotting, dark discharge, heavy/light flow)
Any bleeding between periods?

Any bleeding between periods? Yes No
If yes, when?
Do you Ovulate Y or N? Please explain.
Fertility issues past or present? Please explain.
How many pregnancies have you had?
How many children?
Ages of children
Any problems with your pregnancies?
Any interrupted pregnancies?

Any interrupted pregnancies? Yes No
If yes, please explain.
Are you or have you suffered from postpartum depression Y or N? Please explain
Have you had a hysterectomy?

Have you had a hysterectomy? Yes No
Date
Age
Ovaries removed?

Ovaries removed? Yes No
Have you had a tubal ligation?

Have you had a tubal ligation? Yes No
Date
Do you have a family history of any of the following?
Uterine Cancer

Uterine Cancer Myself
Family Member(s)
Ovarian Cancer

Ovarian Cancer Myself
Family Member(s)
Colon Cancer

Colon Cancer Myself
Family Member(s)
Fibrocystic Breast

Fibrocystic Breast Myself
Family Member(s)
Breast Cancer

Breast Cancer Myself
Family Member(s)
Heart Disease

Heart Disease Myself
Family Member(s)
Osteoporosis

Osteoporosis Myself
Family Member(s)
Thyroid

Thyroid Myself
Family Member(s)
Autoimmune

Autoimmune Myself
Family Member(s)
Other

Other Myself
Family Member(s)
List additional family history
Have you had any of the following tests performed? Check those that apply and note the date
Mammography

Mammography Yes No
Date
Pap Smear

Pap Smear Yes No
Date
Bone Density

Bone Density Yes No
Date
Thyroid tested

Thyroid tested Yes No
Date
List any surgeries you have had and approximate date(s)
List any additional tests that have been preformed and note the date.
Have any of these test results been abnormal? If YES, please explain.
Since you first began having a period, have you ever had what YOU would consider to be an abnormal cycle?

Since you first began having a period, have you ever had what YOU would consider to be an abnormal cycle? Yes No
If YES, please explain (such as the approximate date, age when this occurred, and the symptoms experienced)
Do you have, or did you ever have Premenstrual Syndrome (PMS)?

Do you have, or did you ever have Premenstrual Syndrome (PMS)? Yes No
If YES, explain symptoms
Examine breasts monthly

Examine breasts monthly Yes No
Ever experienced breast pain, discomfort, etc.

Ever experienced breast pain, discomfort, etc. Yes No
Ever been diagnosed with lumps, fibroids, breast cancer, etc.

Ever been diagnosed with lumps, fibroids, breast cancer, etc. Yes No
What are your goals with taking Bio-Identical Hormone Replacement Therapy?
Do you understand the concept of Bio-Identical Hormone Replacement Therapy?

Do you understand the concept of Bio-Identical Hormone Replacement Therapy? Yes No
Please write down any questions you have about Bio-Identical Hormone Replacement Therapy
Patient Symptoms

Rate your current status for each symptom by checking the appropriate modifier. Feel free to use additional space to describe any symptoms. This section may be repeated upon subsequent visits.
Today's Date

* If you mark YES, please rank mild, moderate or severe.

SYMPTOM
	No	Yes 1-Mild	Yes 2-Moderate	Yes 3-Severe
Fibrocystic Breast	Fibrocystic BreastNo	Fibrocystic BreastYes 1-Mild	Fibrocystic BreastYes 2-Moderate	Fibrocystic BreastYes 3-Severe
Nipple Sensitivity	Nipple SensitivityNo	Nipple SensitivityYes 1-Mild	Nipple SensitivityYes 2-Moderate	Nipple SensitivityYes 3-Severe
Breast Tenderness	Breast TendernessNo	Breast TendernessYes 1-Mild	Breast TendernessYes 2-Moderate	Breast TendernessYes 3-Severe
Heavy/Irregular Menses	Heavy/Irregular MensesNo	Heavy/Irregular MensesYes 1-Mild	Heavy/Irregular MensesYes 2-Moderate	Heavy/Irregular MensesYes 3-Severe
Breakthrough Bleeding	Breakthrough BleedingNo	Breakthrough BleedingYes 1-Mild	Breakthrough BleedingYes 2-Moderate	Breakthrough BleedingYes 3-Severe
Abnormal Bleeding	Abnormal BleedingNo	Abnormal BleedingYes 1-Mild	Abnormal BleedingYes 2-Moderate	Abnormal BleedingYes 3-Severe
Cramps	CrampsNo	CrampsYes 1-Mild	CrampsYes 2-Moderate	CrampsYes 3-Severe
Pelvic Pain	Pelvic PainNo	Pelvic PainYes 1-Mild	Pelvic PainYes 2-Moderate	Pelvic PainYes 3-Severe
Pelvic Pressure	Pelvic PressureNo	Pelvic PressureYes 1-Mild	Pelvic PressureYes 2-Moderate	Pelvic PressureYes 3-Severe
Pelvic Fullness	Pelvic FullnessNo	Pelvic FullnessYes 1-Mild	Pelvic FullnessYes 2-Moderate	Pelvic FullnessYes 3-Severe
Fluid Retention/Bloating	Fluid Retention/BloatingNo	Fluid Retention/BloatingYes 1-Mild	Fluid Retention/BloatingYes 2-Moderate	Fluid Retention/BloatingYes 3-Severe
Vaginal Dryness	Vaginal DrynessNo	Vaginal DrynessYes 1-Mild	Vaginal DrynessYes 2-Moderate	Vaginal DrynessYes 3-Severe
Bladder Symptoms	Bladder SymptomsNo	Bladder SymptomsYes 1-Mild	Bladder SymptomsYes 2-Moderate	Bladder SymptomsYes 3-Severe
Urinary Frequency	Urinary FrequencyNo	Urinary FrequencyYes 1-Mild	Urinary FrequencyYes 2-Moderate	Urinary FrequencyYes 3-Severe
Frequent Urinary Tract Infection (UTI)	Frequent Urinary Tract Infection (UTI)No	Frequent Urinary Tract Infection (UTI)Yes 1-Mild	Frequent Urinary Tract Infection (UTI)Yes 2-Moderate	Frequent Urinary Tract Infection (UTI)Yes 3-Severe
Harder to Reach Climax	Harder to Reach ClimaxNo	Harder to Reach ClimaxYes 1-Mild	Harder to Reach ClimaxYes 2-Moderate	Harder to Reach ClimaxYes 3-Severe
Decreased Sex Drive	Decreased Sex DriveNo	Decreased Sex DriveYes 1-Mild	Decreased Sex DriveYes 2-Moderate	Decreased Sex DriveYes 3-Severe
Uncomfortable Intercourse	Uncomfortable IntercourseNo	Uncomfortable IntercourseYes 1-Mild	Uncomfortable IntercourseYes 2-Moderate	Uncomfortable IntercourseYes 3-Severe
Loss of Vitality	Loss of VitalityNo	Loss of VitalityYes 1-Mild	Loss of VitalityYes 2-Moderate	Loss of VitalityYes 3-Severe
New Facial Hair	New Facial HairNo	New Facial HairYes 1-Mild	New Facial HairYes 2-Moderate	New Facial HairYes 3-Severe
Dry Skin/Hair	Dry Skin/HairNo	Dry Skin/HairYes 1-Mild	Dry Skin/HairYes 2-Moderate	Dry Skin/HairYes 3-Severe
Weight Gain/Increased Appetite	Weight Gain/Increased AppetiteNo	Weight Gain/Increased AppetiteYes 1-Mild	Weight Gain/Increased AppetiteYes 2-Moderate	Weight Gain/Increased AppetiteYes 3-Severe
Food/Sweets/Salt Cravings	Food/Sweets/Salt CravingsNo	Food/Sweets/Salt CravingsYes 1-Mild	Food/Sweets/Salt CravingsYes 2-Moderate	Food/Sweets/Salt CravingsYes 3-Severe
Fluid Retention	Fluid RetentionNo	Fluid RetentionYes 1-Mild	Fluid RetentionYes 2-Moderate	Fluid RetentionYes 3-Severe
Hot Flashes	Hot FlashesNo	Hot FlashesYes 1-Mild	Hot FlashesYes 2-Moderate	Hot FlashesYes 3-Severe
Night Sweats	Night SweatsNo	Night SweatsYes 1-Mild	Night SweatsYes 2-Moderate	Night SweatsYes 3-Severe
Headaches	HeadachesNo	HeadachesYes 1-Mild	HeadachesYes 2-Moderate	HeadachesYes 3-Severe
Backaches	BackachesNo	BackachesYes 1-Mild	BackachesYes 2-Moderate	BackachesYes 3-Severe
Joint Pains	Joint PainsNo	Joint PainsYes 1-Mild	Joint PainsYes 2-Moderate	Joint PainsYes 3-Severe
Muscle Pains	Muscle PainsNo	Muscle PainsYes 1-Mild	Muscle PainsYes 2-Moderate	Muscle PainsYes 3-Severe
Arthritis	ArthritisNo	ArthritisYes 1-Mild	ArthritisYes 2-Moderate	ArthritisYes 3-Severe
Heart Palpitations	Heart PalpitationsNo	Heart PalpitationsYes 1-Mild	Heart PalpitationsYes 2-Moderate	Heart PalpitationsYes 3-Severe
Crawling Feeling Under Skin	Crawling Feeling Under SkinNo	Crawling Feeling Under SkinYes 1-Mild	Crawling Feeling Under SkinYes 2-Moderate	Crawling Feeling Under SkinYes 3-Severe
Swelling of Hands	Swelling of HandsNo	Swelling of HandsYes 1-Mild	Swelling of HandsYes 2-Moderate	Swelling of HandsYes 3-Severe
Swelling of Ankles	Swelling of AnklesNo	Swelling of AnklesYes 1-Mild	Swelling of AnklesYes 2-Moderate	Swelling of AnklesYes 3-Severe
Swelling of Breasts	Swelling of BreastsNo	Swelling of BreastsYes 1-Mild	Swelling of BreastsYes 2-Moderate	Swelling of BreastsYes 3-Severe
Tightness in Neck/Shoulders	Tightness in Neck/ShouldersNo	Tightness in Neck/ShouldersYes 1-Mild	Tightness in Neck/ShouldersYes 2-Moderate	Tightness in Neck/ShouldersYes 3-Severe
Depression	DepressionNo	DepressionYes 1-Mild	DepressionYes 2-Moderate	DepressionYes 3-Severe
Confusion/Difficulty Concentrating	Confusion/Difficulty ConcentratingNo	Confusion/Difficulty ConcentratingYes 1-Mild	Confusion/Difficulty ConcentratingYes 2-Moderate	Confusion/Difficulty ConcentratingYes 3-Severe
Anxiety	AnxietyNo	AnxietyYes 1-Mild	AnxietyYes 2-Moderate	AnxietyYes 3-Severe
Mood Swings	Mood SwingsNo	Mood SwingsYes 1-Mild	Mood SwingsYes 2-Moderate	Mood SwingsYes 3-Severe
Crying Easily	Crying EasilyNo	Crying EasilyYes 1-Mild	Crying EasilyYes 2-Moderate	Crying EasilyYes 3-Severe
Angry Outbursts/Arguments/Violent Tendencies	Angry Outbursts/Arguments/Violent TendenciesNo	Angry Outbursts/Arguments/Violent TendenciesYes 1-Mild	Angry Outbursts/Arguments/Violent TendenciesYes 2-Moderate	Angry Outbursts/Arguments/Violent TendenciesYes 3-Severe
Fatigue	FatigueNo	FatigueYes 1-Mild	FatigueYes 2-Moderate	FatigueYes 3-Severe
Loss of Memory	Loss of MemoryNo	Loss of MemoryYes 1-Mild	Loss of MemoryYes 2-Moderate	Loss of MemoryYes 3-Severe
Diminished Sense of Taste	Diminished Sense of TasteNo	Diminished Sense of TasteYes 1-Mild	Diminished Sense of TasteYes 2-Moderate	Diminished Sense of TasteYes 3-Severe
Decreased Vision	Decreased VisionNo	Decreased VisionYes 1-Mild	Decreased VisionYes 2-Moderate	Decreased VisionYes 3-Severe
Difficulty Falling Asleep	Difficulty Falling AsleepNo	Difficulty Falling AsleepYes 1-Mild	Difficulty Falling AsleepYes 2-Moderate	Difficulty Falling AsleepYes 3-Severe
Difficulty Staying Asleep	Difficulty Staying AsleepNo	Difficulty Staying AsleepYes 1-Mild	Difficulty Staying AsleepYes 2-Moderate	Difficulty Staying AsleepYes 3-Severe

Confidential Female Hormone Evaluation

Confidential Female Hormone Evaluation

Practitioner(s) currently seeing

Nutritional/Natural Supplements:

Current Prescription Medications

List Hormones previously taken

Habits

Medical History

Do you have a family history of any of the following?

Have you had any of the following tests performed? Check those that apply and note the date

Patient Symptoms