Todays Date
E-mail Address: *
Birth Date
Zip Code
Home Phone
Mobile Phone
Do You Use Tobacco?
Do You Use Alcohol
Do You Use Caffeine?
Doctors Name
Doctors Address
Doctors Phone Number
Do you have any allergies?
Please Describe the Allergic Reaction you Experienced and When it Occured
Do you use any Over The Counter Products? Please list
Diet: Please list your intake on a typical day
Medical Conditions/Diseases: Please check all that apply to youHeart Disease
High Cholesterol or lipids
High Blood Pressure
Ulcers: Stomach or Esophagus
Prostate Problems
Lung Condition (Asthma, Emphysema, COPD)
Blood Clotting Problems
Arthritis or Joint Problems
Seizure Disorder (Epilepsy)
Thyroid Disease (Overactive or Underactive Thyroid)
Eye Disease (Glaucoma, etc.)
Hormonal Related Issues
Current Prescription Medications
Preferred Dosage Forms
Do You Have a Family History of the Following: Please check all that applyUterine Cancer
Heart Disease
Fibrocystic Breast
Breast Cancer
Ovarian Cancer
Have You Had Any of the Following Tests Performed? Check all that apply and please note the last date of each testMammography
PAP Smear
Date of Last Doctor Visit and Type of Doctor Last Seen
How Did You Arrive at the Decision to Consider Bio-Idential Hormone Replacement Therapy?
What are Your Goals with Taking BHRT?
List Hormones Previously Taken
Have you ever used oral contraceptives before
Have you ever experienced any problems with oral contraceptives
How many pregnancies have you had?
How many children do you have?
Any interrupted pregnancies
Have you had a hysterectomy?
Have you had your ovaries removed?
Have you had a tubal ligation?
Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles?
If Yes, Please explain (Such as age when this occurred, symptoms, etc.)
When was your last period?
How many days did your last period last?
Do you have, or did you ever have Premenstrual Syndrome (PMS)?
If Yes, please explain symptoms
Please write down any questions you have about Bio-Idential Hormone Replacement Therapy

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