Female Hormone Questionnaire Survey

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* Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

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* Phone Number(s)

Home

Mobile

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* Date of Birth

Date of Birth

Date

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* Allergies to medications or Foods (Drug/Food name & reaction experienced)

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* Height (in)

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* Weight (lbs)

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* Do you have prescription drug insurance?

Yes

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* Insurance Company

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* Insurance ID#

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* Rx Group #

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* Rx Bin #

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* Doctor's Name

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* Doctor's Phone

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* What are your main reasons for seeking care?

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* Are you taking hormones? If so what is your regimen?

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* List any previous hormone therapy you have tried:

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* List your prescribed drugs and over-the-counter drugs, such as vitamins, nutritional or natural products you are currently taking:

SURGERY AND MEDICAL HISTORY
All questions contained in this questionnaire are optional and will be kept strictly confidential.

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* Have you had any of the following surgeries?

Hysterectomy

Ovaries Removed

Ablation

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* Hysterectomy Date (If Applicable)

Date

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* Ovary Removal Date (If applicable)

Date

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* Ablation Date (If applicable)

Date

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* Check any of the following conditions you have had previously or currently:

Thyroid disease

Fibrocystic breast disease

Endometriosis

Blood clotting disorder

High blood pressure

High cholesterol

Heart disease

Stroke

Headaches/Migraines

Lupus/Fibromyalgia/Autoimmune disease

Osteoporosis

Cancer

Type 1 Diabetes

Type 2 Diabetes

Other

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* Is there a family history of…?

Uterine cancer

Ovarian cancer

Breast cancer

Osteoporosis

Heart disease

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* If you have a family history of above, what's their relation to you?

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* Do you still have your period?

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* If you still have regular periods, what was the date of your last period?

Date

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* Have you had a mammogram?

Yes

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* If you have had a mammogram, within the last 12 months, when was the date? (If you have not had a mammogram and need to bypass this question, please indicate field with date of 01/01/1900.)

Date

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* Have you had a bone density test within the last 3 years?

Yes

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* Do you or did you have PMS or PMDD?

Yes

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* Do you have cramps?

Yes

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* Have you ever taken birth control pills?

Yes

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* If yes, which one?

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* Do you use alcohol? If yes how much?

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* RATE THE FOLLOWING IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS RECENTLY.

	0 None	1 Mild	3 Moderate	4 Severe
Sleep disruption/Insomnia	Sleep disruption/Insomnia 0 None	Sleep disruption/Insomnia 1 Mild	Sleep disruption/Insomnia 3 Moderate	Sleep disruption/Insomnia 4 Severe
Decreased libido (sex drive)	Decreased libido (sex drive) 0 None	Decreased libido (sex drive) 1 Mild	Decreased libido (sex drive) 3 Moderate	Decreased libido (sex drive) 4 Severe
Night sweats	Night sweats 0 None	Night sweats 1 Mild	Night sweats 3 Moderate	Night sweats 4 Severe
Depression	Depression 0 None	Depression 1 Mild	Depression 3 Moderate	Depression 4 Severe
Fluid retention	Fluid retention 0 None	Fluid retention 1 Mild	Fluid retention 3 Moderate	Fluid retention 4 Severe
Vaginal dryness	Vaginal dryness 0 None	Vaginal dryness 1 Mild	Vaginal dryness 3 Moderate	Vaginal dryness 4 Severe
Migraines/headaches	Migraines/headaches 0 None	Migraines/headaches 1 Mild	Migraines/headaches 3 Moderate	Migraines/headaches 4 Severe
Irritability	Irritability 0 None	Irritability 1 Mild	Irritability 3 Moderate	Irritability 4 Severe
New facial hair	New facial hair 0 None	New facial hair 1 Mild	New facial hair 3 Moderate	New facial hair 4 Severe
Nervousness/anxiety	Nervousness/anxiety 0 None	Nervousness/anxiety 1 Mild	Nervousness/anxiety 3 Moderate	Nervousness/anxiety 4 Severe
Decreased quality of orgasm or intercourse	Decreased quality of orgasm or intercourse 0 None	Decreased quality of orgasm or intercourse 1 Mild	Decreased quality of orgasm or intercourse 3 Moderate	Decreased quality of orgasm or intercourse 4 Severe
Hot flashes	Hot flashes 0 None	Hot flashes 1 Mild	Hot flashes 3 Moderate	Hot flashes 4 Severe
Breast tenderness	Breast tenderness 0 None	Breast tenderness 1 Mild	Breast tenderness 3 Moderate	Breast tenderness 4 Severe
Dry skin	Dry skin 0 None	Dry skin 1 Mild	Dry skin 3 Moderate	Dry skin 4 Severe
Mood swings	Mood swings 0 None	Mood swings 1 Mild	Mood swings 3 Moderate	Mood swings 4 Severe
Crying easily	Crying easily 0 None	Crying easily 1 Mild	Crying easily 3 Moderate	Crying easily 4 Severe
Weight gain	Weight gain 0 None	Weight gain 1 Mild	Weight gain 3 Moderate	Weight gain 4 Severe
Short term memory loss	Short term memory loss 0 None	Short term memory loss 1 Mild	Short term memory loss 3 Moderate	Short term memory loss 4 Severe
Painful intercourse	Painful intercourse 0 None	Painful intercourse 1 Mild	Painful intercourse 3 Moderate	Painful intercourse 4 Severe
Poor concentration	Poor concentration 0 None	Poor concentration 1 Mild	Poor concentration 3 Moderate	Poor concentration 4 Severe
Food cravings	Food cravings 0 None	Food cravings 1 Mild	Food cravings 3 Moderate	Food cravings 4 Severe
Backaches	Backaches 0 None	Backaches 1 Mild	Backaches 3 Moderate	Backaches 4 Severe
Hair loss	Hair loss 0 None	Hair loss 1 Mild	Hair loss 3 Moderate	Hair loss 4 Severe
Fatigue	Fatigue 0 None	Fatigue 1 Mild	Fatigue 3 Moderate	Fatigue 4 Severe
Acne	Acne 0 None	Acne 1 Mild	Acne 3 Moderate	Acne 4 Severe
Oily skin	Oily skin 0 None	Oily skin 1 Mild	Oily skin 3 Moderate	Oily skin 4 Severe
Dry eyes	Dry eyes 0 None	Dry eyes 1 Mild	Dry eyes 3 Moderate	Dry eyes 4 Severe
Decreased muscle mass	Decreased muscle mass 0 None	Decreased muscle mass 1 Mild	Decreased muscle mass 3 Moderate	Decreased muscle mass 4 Severe
Bleeding changes or disorders	Bleeding changes or disorders 0 None	Bleeding changes or disorders 1 Mild	Bleeding changes or disorders 3 Moderate	Bleeding changes or disorders 4 Severe
Heart palpitations	Heart palpitations 0 None	Heart palpitations 1 Mild	Heart palpitations 3 Moderate	Heart palpitations 4 Severe
Brittle or breaking nails	Brittle or breaking nails 0 None	Brittle or breaking nails 1 Mild	Brittle or breaking nails 3 Moderate	Brittle or breaking nails 4 Severe
Thinning of skin	Thinning of skin 0 None	Thinning of skin 1 Mild	Thinning of skin 3 Moderate	Thinning of skin 4 Severe

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* Do you use tobacco products?

Yes. If so, we will need a signed release form from your current physician before we can participate in a recommendation.

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* Do you get physical exercise? If yes, what type and how often?

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* Do you have any questions, comments or concerns regarding Natural Hormone Replacement Therapy?

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* How did you hear about us?

Radio

TV Channel 41

TV Channel 9

Invitation in Mail

Facebook

YouTube

Website

Other