Health Summary Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

What is your height and current weight?

Are you experiencing any of the following symptoms (select all that apply):

Hot flashes

Night Sweats

Vaginal Dryness

Erectile Dysfunction

Urinary Urgency/Incontinence

Regular Headaches

Migraines

Insomnia

Mood Swings

Irritability

Weight gain

Low Libido

Difficult Orgasm

Anger/Rage

Irritabilitity

Depression

Anxiety

PMS

Fatigue

Hair Loss

Facial Hair/Body Hair

Frequent UTIs/Yeast Infections

Poor Memory

Poor Concentration/Focus

Lack of Motivation

Weight Loss

Achy Joints

Acne

Heart Palpitations

Loss of Muscle Mass

Dry Eye/Skin

Osteoporosis/osteopenia

High Stress (significantly impacting my ability to function)

Breast Tenderness

Swelling

Clotting with Cycle

Menstrual Cramping

Do you any have medication allergies or alpha gal syndrome? Please explain.

What is your main goal for hormone replacement therapy?

Who is the provider that you would like us to contact for any prescription recommendations?

Provider's Phone and Fax Number?

Who referred you to us?

List significant medical history and significant family history (please list all diagnosed conditions and surgeries for yourself):

Please upload any labs you'd like the pharmacist to review.

List all current medications and supplements (including injectables and IUDs):

Medication List Upload

Diet

Exercise

How many pregnancies have you had? How many children?

Are you wanting to have any more children? If no, how are you preventing pregnancy?

When was the first day of your last period?

How many days do you have between your cycles? How long does the flow last? What is the flow like?

Have you taken any hormone replacement before? What therapy? How did you tolerate it?

When was your last mammogram and pelvic exam? Were they normal?

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