First Name
Mi
Last Name
Address
City
State
Zip
Phone Number
Email
Date of Birth
Age
Height
Weight
Marital Satus
Tobacco
If yes how many Pks?
Alcohol Consumption
Amount Used per week
Soda or Carbonated Beverages
How many per week?
Occupatuion
Primary Care Physician
Physician' Address
Physician City
Physician's State & Zip
Office Phone Number
Physician's Fax Number (needed)
OBGYN Physician's Name
Physician's Address
Physicians City, State, Zip
Physian's Phone Number
Physicians Fax Number
Non Prescription drugs
Current Prescriptions
Current Diagnosis
Current Diagnosis Continued
Past Hormones
Exercise Times Per Week
Number of Pregnancies
Number of Children
Any Miscarriages
Hysterectomy Yes or No
Date
Ovaries Removed & Date
Tubbal Ligation and Date
Abalation Yes or No and Date
Family History of Breast Cancer
Date of Last Mamogram
Date of Last Pap
Date of Last Period
How Long in Days
Abnormal Yes or No
If Abnormal Explain
Age of First Period
Referred By?
Have any Questions about BHRT?
Goal for Hormone Therapy
Increased Forgetfulness
Foggy Thinking
Tearful
Sadness-Depression
Mood Swings
Fluid Retention-Bloating
Stress
Anxious
Irritable
Nervous
Decrease Mental Sharpness
Morning Fatigue
Afternoon Fatigue
Evening Fatigue
Difficulty Falling Asleep
Difficulty Staying Asleep
Decreased Stamina
Ringing in Ears
Allergies
Headaches/Migraines
Dizzy Spells
Sugar Cravings /Carb Cravings
Constipation
Goiter
Cold Body Temperature
Hoarseness
Hair Dry or Brittle
Nails Breaking or Brittle
Slow Pulse Rate
Rapid Heartbeat
Heart Fluttering/Palpitations
Incontinence
Hot Flashes
Night Sweats
Infertility Concerns
Acne
Scalp Hair Loss
Weight Gain Hips
Weight Gain Waist
High Cholesterol
Elevate Triglycerides
Decreased Libido
Decreased Muscle Size
Decreased Flexibility
Burned Out Feeling
Sore Muscles
Increased Joint Pain
Neck or Back Pain
Bone Loss
Thinning Skin
Rapid Aging
Aches and Pains
Irritable Bowel Syndrome
Vaginal Dryness
Irregular Periods
Uterine Fibroids
Breast Tenderness
Fibrocystic Breasts
Increased Facial/Body Hair
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