Hormone Replacement Therapy

,

Do you use tobacco?
Do you use alcohol?
Do you use caffeine?

If yes, how often/how much
If yes, how often/how much
If yes, how often/how much

Physician's Information:
Allergies: (select all that apply)

   
Other:
Over the Counter Issues:

     
Other:
Nutritional / Natural Substances: (please identify & list products you are using)
Vitamins:
Minerals:
Herbs:		 Enzymes:
Nutritional / Protein Suppliments:
Others:

Medical Conditions:

     
Other:

Current Prescription Medications:




List Hormones Previously Taken:



Bone Size: Body Type:
Have you ever taken oral contraceptives?

Please describe problems
When was your last period?
Have you had a hysterectomy? If so, the date
Were your ovaries removed?
Have you had a tubal ligation? If so, the date
Do you have a family history of any of the following?
Uterine cancer Family Member(s)
Ovarian cancer Family Member(s)
Fibrocystic breast disease Family Member(s)
Breast cancer Family Member(s)
Heart disease Family Member(s)
Osteoporosis Family Member(s)
Have you had any of the following tests performed?
Mammography If so, the date
PAP Smear If so, the date
Since you first began having periods, have you ever had what you consider to be abnormal cycles?
If yes, please explain (such as age when this occurred and symptoms)
Do you have, or did you ever had Premenstrual Syndrome (PMS)?
If yes, please explain
How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?
What are your goals with taking BHRT?
Please enter any questions your have about BHRT.
Symptom Analysis
Fibrocystic Breast Heavy/Irregular Menses Dry Skin/Hair
Depression Arthritis Mood Swings
Vaginal Dryness Harder to reach climix Sleep Disturbances
Irritability Weight Gain Fluid Retention
Breast Tenderness Hot Flashes Fatigue
Cramps Anxiety Bladder Symptoms
Breakthrough Bleeding Night Sweats Decreased Sex Drive
Loss of memory Headaches Hair Loss

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