CONFIDENTIAL FEMALE

HORMONE EVALUATION

Please complete prior to your first appointment

Today's Date

First & Last Name

Phone

Date of Birth

Year

Month

Day

Height

Weight

Occupation

Do you use tobacco, CBD or THC? If yes, how often and how much?

Do you use alcohol? If yes, how often and how much?

Do you use caffeine? If yes, how often and how much?

Do you exercise? If yes, what type of exercise and for how long have you been exercising?

How many hours of sleep do you typically get per night and are they uninterrupted? If they're interrupted, what time and for what reason (children, night shift, health concerns, etc)

Do you wake rested or tired (even when getting 7- 8 hours of sleep?)

What would you like to change about your current dietary choices?

Allergies: Please list any allergies and describe the reaction that occurred.

Drugs

Food

Other

Medical Conditions/ Diseases

Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include heart disease. high blood pressure, depression, ulcers, arthritis, insominia, etc.)

Do you have a family history of Osteoporosis or blood clotting disorders? If yes, through which family member?

Do you have a family history of Breast, Uterine or Ovarian Cancer? If yes, through which family member?

Over-the-Counter Medication History:

Please list all the non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):

Current Prescription Medications

Please list all the current prescription medications you're taking. Include name and strength, date started, how often per day, and medical condition being treated.

Please list all hormones previously or currently taken. Include name, date started, date stopped, and reason for taking them.

Have you ever used oral contraceptives (birth control)?

If you experienced any problems, Please describe:

How many pregnancies have you had?

How many children?

Have you had any interrupted pregnancies?

Have you had a tubal ligation? If yes, Date of Surgery

Have you had a hysterectomy? If yes, date of surgery and reason for hysterectomy. Do your ovaries remain?

Have you had an endometrial ablation? If yes, date of surgery.

Have you had a Mammography, PAP smear or bone density test performed? If yes, date of test and outcome.

What age did your period start?

When was your last period and how many days did it last?

How many days is/was your cycle (example: 28 days) and is/was your menstrual flow heavy or light? Do you experience clotting?

Have you ever had what YOU would consider to be an abnormal cycles? If yes, please explain.

At what age (if known) did your mother, maternal aunts, and/or sisters go through menopause?

What is your primary goal for taking hormone replacement therapy?

Monday to Friday 9:00 AM - 5:30 PM

Closed on Weekends & Holidays

CONFIDENTIAL FEMALE

HORMONE EVALUATION