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HME/DME Rental Equipment Menu Hormone Consultation Form Request for Information (Online) WholeLifeRx

Hormone Consultation Form

First Name

Last Name

Contact Number *

Height *

Weight *

Desired Weight *

Do you use tobacco? *

Yes

If yes, how much?

Do you use alcohol? *

Yes

If yes, how much?

Do you use caffeine? *

Yes

If yes, how much?

Do you exercise? *

Yes

If yes, how much?

Do you have allergies to food/drugs/other? *

Over The Counter Medications *

Including vitamins, herbals, and supplements

Mecial Conditions/Diseases? *

Please list any conditions/diseases that you have been diagnosed with or suffer from.

Current Prescription Medications *

Including hormones. Please list dosage and frequency

List Hormones Previously Taken

Have you ever used oral contraceptives *

If you experienced any problems, please describe

Have you had a tubal ligation?

Have you had a hysterectomy? *

If so, were your ovaries removed?

Do you have a family history of cancer or osteoporosis? *

Is/Was your menstrual flow heavy or light? *

How many days is/was your cycle? *

Have you ever had what you would consider to be abnormal cycles? *

Yes/No and explain

When was your last period? How long did it last?

Do you or have you ever suffered from Premenstrual Syndrome (PMS)?

Yes/No and explain

Hot Flashes *

Night Sweats *

Vaginal Dryness *

Incontinence *

Bleeding Changes *

Fibrocystic Breast *

Weight gain *

Fluid Retention *

Dry Skin/Hair *

Hair Loss *

Anxiety *

Depression *

Mood Swings *

Irritability *

Headaches/Migraines *

Breast Tenderness *

Cramps *

Difficulty Falling Asleep *

Difficulty Staying Asleep *

Fatigue *

Loss of Memory/Mental Clarity *

Foggy Thinking *

Acne *

Arthritis *

Decreased Libido *

Stress *

Other symptoms

What are your goals for Hormone Replacement Therapy? *

What doctors should we contact for this therapy? *

Name and phone number

* Required field