Hormone Evaluation (Female) Intake Form

Hormone Evaluation (Female) Intake Form
Name

First NameLast Name
Date of birth:
MM/DD/YYYY
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Doctor's Name:
Doctor's Address:
Doctor's Phone Number:
Please enter a valid phone number.
Height: feet inches
Weight: pounds
BMI (pharmacist will calculate):
BMI = weight in kg/height in meters^2
Bone size:
Body Type:
Waist circumference (inches):
Hip circumference (inches):
Waist/hip ratio:
Your birth weight (lbs):
How were you born?

Natural deliveryC-section
How many pregnancies have you had?
How many children do you have?
Have you ever had a miscarriage?

YesNo
Did you breastfeed your children?

YesNo
Have you had any of the following? (Select all that apply)

HysterectomyOvaries removedTubal ligation
If yes to any of the above procedures, please list date of surgery and reason why
Do you use birth control?

YesNo
Please list any complications:
When was your last period?
How long did it last?
Age at which your menstrual period began:
Since that time, have you ever had what you would consider to be abnormal cycles?

YesNo
If yes, please explain:
Do you have, or did you ever have Premenstrual Syndrome (PMS)?

YesNo
If yes, please explain your symptoms:
Please list any recent surgeries (including gastric bypass or augmentations if applicable):

Have you had any of the following tests performed?

	No	Yes	Date of test:
Colonoscopy
Mammogram
Bone Density
PAP Smear

Allergies (select all that apply):

PenicillinMorphineCodeineSulfa drugAspirinFood allergiesDye allergiesNitrate allergyPet allergiesSeasonal allergiesNo known allergiesOther
Please describe your allergic reaction, if applicable:
Medical Conditions/Diseases (select all that apply):

Heart disease (Ex: congestive heart failure)High cholesterolHigh blood pressureDepressionUlcersHypothyroidismHyperthyroidismEmphysemaCOPDAsthmaPsoriasisIrritable bowel syndrome (IBS/IBD)High triglyceridesArthritisHeadaches/migrainesChronic painBlood clotting problemsDiabetesCancerEpilepsyGERDGlaucomaFibromyalgiaOther

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

	No	Yes	If yes, which family member(s)?
Uterine Cancer
Ovarian Cancer
Fibrocystic Breast
Breast Cancer
Heart Disease
Osteoporosis
Colon Cancer
Diabetes
Thyroid

Do you smoke?

YesNo
If yes, how much and for how long?
How many caffeinated beverages do you drink per day?
Portion size:
How much water do you drink per day?
Portion size:
How many alcoholic beverages do you consume in an average week?
How many bowel movements do you have per day?
Do you experience any of the following?

ConstipationDiarrheaGasBloating
Any recent weight changes?

YesNo
If so, did it increase or decrease? By how much?
How many meals do you eat in a day?
Please describe your typical breakfast:
Please describe your typical lunch:
Please describe your typical dinner:

Please answer the following questions about your sleep habits:

	No	Yes
Do you have trouble waking up in the mornings?
Do you take naps during the day?
Do you have trouble falling asleep at night?
Do you have trouble staying asleep?
Do you have sleep apnea?

Comments about sleep patterns:
Occupation:
Do you work outside the home?

YesNo
How many hours per week?
Do you enjoy your job?
Do you find your job stressful?
Do you find your job satisfying?
Do you take care of small children, elderly, or disabled adults?

YesNo
If yes, please explain:
Do you have a hobby?
What activity relaxes you?
How often are you able to do this activity?
Is there a place in your home that you can go to relax and be alone?

YesNo
Do you belong to a social or activity group outside of your family?

YesNo
Do you have a current exercise routine?

YesNo
If yes, what kind of exercise and how often per week?
How did you arrive at the decision to consider Bio-identical Hormone Replacement Therapy (BHRT)?
What are your goals with taking BHRT?
What questions do you have about BHRT?
Please list current medication and supplements:
Name of medication, dose, times per day, and the date started
Life Stress Test

Death of spouseDivorceMarital separationJail termDeath of close family memberPersonal injury or illnessMarriageFired from workMarital reconciliationRetirementChange in family members healthPregnancySex difficultiesAddition to familyBusiness readjustmentChange in financial statusDeath of close friendChange to a different line of workChange in number of marital argumentsMortgage or loan over $10,000Foreclosure of mortgage or loanChange in work responsibilitiesTrouble with in-lawsOutstanding personal achievementSpouse begins or stops workStarting or finishing schoolChange in living conditionsRevision of personal habitsTrouble with bossChange in work hours or conditionsChange in residenceChange in schoolsChange in recreational habitsChange in social activitiesMortgage or loan under $10,000Change in sleeping habitsChange in number of family gatheringsChange in eating habitsVacationChristmas seasonMinor violations of the law
Life Stress Test Total

Category 1: Basic Hormone Imbalance (please rate the following symptoms)

	None	Mild	Moderate	Severe
Hot flashes
Mood swings (PMS)
Urinary incontinence
Night sweats
Heart palpitations
Cystic ovaries
Vaginal dryness
Acne
Foggy thinking
Sex drive
Depression
Fluid retention
Fibrocystic breasts
Irritability
Increase body/facial hair
Memory loss
Bladder symptoms
Heavy/irregular menses
Headaches
Breast Tenderness
Arthritis
Bone loss
Rapid aging
Painful intercourse
Difficult to reach climax
Weight gain (waist/hip)
Cramps

Category 1 Subtotal:

Category 2: Adrenal Hormone Imbalance (please rate the following symptoms)

	None	Mild	Moderate	Severe
Aches and pains
Morning fatigue
Elevated triglycerides
Bone loss
Sleep disturbances
Depression
Blood sugar imbalance
Anxiety
Infertility
Nervousness
Allergic conditions
Evening fatigue
Autoimmune illness
Chronic illness
Susceptibility to infections
Sugar cravings
Night sweats
Foggy thinking
Irritability
Memory lapse
Weight gain (waist)
Afternoon fatigue
Get a "second wind"
Stress
Decrease stamina
Low blood pressure
Low libido

Category 2 Subtotal:

Category 3: Thyroid Hormone Imbalance (please rate the following symptoms)

	None	Mild	Moderate	Severe
Aches and pains
Sleep disturbances
Inability to lose weight
Depression
Dry/brittle nails
Dry skin
Cold hands and feet
Headaches
Infertility
Foggy thinking
Menstrual irregularities
Thinning hair
Constipation
Low libido
Feeling cold all the time
Fatigue
Elevated cholesterol
Heart palpitations
Weight gain
Dry/brittle hair

Category 3 Subtotal:
Additional labs desired to help in your consultation:
- Blood sugar and A1c
- Lipids/cholesterol or Spectracell Cardiometabolic Profile
- Iron/blood count (ferritin)
- Micronutrient test from Spectracell
- Vitamin D
- Vitamin B12
- TSH, Free T4, Free T3, TPO and Thyroid Antibodies (& Reverse T3)
- Fasting insulin
- CRP
- Homocysteine
Hormone Panel
- Estriol, estradiol, estrone
- Progesterone
- Testosterone
- DHEA
- Cortisol (morning, afternoon, evening, and bedtime)
Should be Empty: