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Arlington 703-535-8887 Purcellville 540-441-7433

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Hormone Replacement Therapy Forms for Women

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Hormone Replacement Therapy Questionnaire

Enter Your Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Phone #

Age

Occupation

Marital Status

Married

Divorced

Widow

Living with Partner

Single

Emergency Contact:

Health and Background Information

Primary Care Physician

OBGYN Physician

May we share clinical information with your PCP/OBGYN?

Menstrual & Reproductive History

Age at First Period

Date of Last Period

Are Your Periods:

Have you reached menopause?

Number of Pregnancies?

Number of Live Births?

If Yes to Menopause, Age:

History of:

Miscarriages

IVF/Fertility Treatments

Current Symptoms

Hot Flashes

Night Sweats

Vaginal Dryness

Low Libido

Mood Swings

Anxiety/Depression

Fatigue

Weight Gain

Sleep Disturbances

Brain Fog

Hair Thinning

Other Symptoms

Goals for Therapy

Symptom Relief

Energy Levels

Sexual Health

Bone Health

Mood Stablization

Other Goals

Have you used hormone replacement therapy before?

If Yes, Types used:

Estrogen

Progesterone

Testosterone

Bioidentical hormones

If Yes, Methods:

Oral

Patch

Cream/Gel

Injection

Pellet

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 Pressure

Heart Disease

Stroke

Blood Clots (DVT/PE)

Breast Cancer

Ovarian Cancer

Uterine Cancer

Osteoporosis

Thyroid Disorder

Liver Disease

Migraines

Diabetes

Autoimmune Disorders

Mental Health Condition

Other Medical History not Listed above?

Surgical History

breasts Pregnancies? flashes

High Risk Past Medical/Surgical History:

Breast Cancer

Uterine Cancer

Ovarian Cancer

Current Medications & Suppliments

Smoking Status

List 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.)

Mother

Father

Siblings

Grandmother

Grandfather

Lifestyle & Social History

Smoking

Alcohol

Exercise

Diet

If Other, Explain

Sexual Health

Currently Sexually Active

Pain with Intercourse

Contraception Method

How would you rate the stress in your life, 10 being the highest?

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 dryness

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have more wrinkles than the average person your age

Never (0)

Average (1)

Poor (2)

Terrible (3)

You notice a decrease in breast size

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have droopy and sagging breasts

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have hot flashes or night sweats

Never (0)

1-2 per day (1)

8-10 per day (2)

More than 10 per day (3)

You have osteopenia or osteoporosis

Never (0)

Average (1)

Poor (2)

Terrible (3)

Your painful intercourse

Never (0)

Average (1)

Poor (2)

Terrible (3)

You are moody and irritable

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have decreased sex drive

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have decreased memory

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have frequent urinary tract infections

Never (0)

Average (1)

Poor (2)

Terrible (3)

Your menstrual periods are irregular

Never (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 & Acknowledgement

I 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)

Date