Hormone Replacement Patient Consultation Questionnaire

The following questionnaire will help the Pharmacist prepare for your FREE consultation at Solutions Pharmacy. This information will help the pharmacist determine if Hormone Replacement Therapy is right for you. Your answers will be kept confidential and will be reviewed with you in a free private consultation. To share this information with your doctor and/or medical providers you will have to provide authorization. 

Answer the questions according to how you have been feeling in the past few months. 

* 1. Please provide the following information about yourself so the pharmacist can review and prepare for your one-on-one consultation. The pharmacist will call you to schedule the consultation. If you do not want to provide your phone number, you can complete the questionnaire and call to set up your consultation at Solutions Pharmacy at 512.382.9381.

* 2. Rate the degree to which you have experienced the symptoms listed below. Select an answer which best describes how you have been feeling for the past few months.

  None Mild Moderate Severe
Hot Flashes
Night Sweats
Light-Headed Feeling / Dizziness
Headaches
Sleep Disorders / Sleeplessness
Unusual Tiredness / Fatigue
Irritability 
Depression
Anxiety / Tension / Nervousness
Mood Swings / Mood Changes
Confusion / Difficulty Concentrating
Forgetfulness / Short-Term Memory Loss
Angry Outbursts / Arguments / Violent Tendencies
Crying Easily
Backache
Joint Pains
Muscle Pains
Muscle Cramps / Spasms
Problems With Wound Healing Times
Acne / Pimples / Skin Flushing
Dry Skin / Dry Hair
Crawling Feeling Under Skin 
Frequent Urinary Tract Infections 
Urinary Frequency 
Vaginal Dryness
Abnormal Bleeding
Pelvic Pain, Pressure, Fullness or Bloating
Uncomfortable Intercourse
Loss of Sexual Feeling / Desire
Loss of Arousability and Capacity for Orgasm
Loss of Sexual Sensitivity
Discharge or Leaking From Nipples
Breast Tenderness
Loss of Public Hair
Swelling of Hands, Ankles or Breasts
Heart Palpitations
Shortness of Breath
Food / Sweets / Salt Cravings
Increased Appetite / Weight Gain

* 3. Answer the following questions about your lifestyle. 

  Yes No
Do you use alcohol products? 
Do you use tobacco products?
Do you use caffeine products?

* 4. How many ounces of water do you drink in one day (24 hours)?

* 5. Do you have any dietary restrictions (salt, carbohydrates, milk products, red meat etc.)

* 6. Answer the following questions about medical exams to the best of your ability.

* 7. Answer the questions about your menstrual cycle.

* 8. If you still have a period,

* 9. Please answer the following questions. 

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