General Information  ("*" Indicates Required Information)

Name*: DOB*:

Address: City:

Zip:   State*:

Home Phone*:   Work Phone:

Fax:     E-Mail*:

Occupation: Work Hours Per Week:

Marital Status: Single    Married    Divorced    Widowed

How Did You Hear About Natural Hormone Replacement?

Do You Understand The Difference Between Natural & Synthetic Hormones?

What Are Your Goals For Natural Hormone Replacement?

Health Care Provider: Full Name

Address: City:

Phone Number:   Fax:

General Health: Excellent    Good    Fair    Poor   

Height   Weight

Current Diagnosis Or Medical Conditions:

Drug Allergies:   Food Allergies:

Current Medications, Dose, And Duration Of Treatment:

Current Vitamins/Herbs, Dose, And Duration Of Treatment:

Medical Status:   

Cholesterol Date     Blood Pressure Date

Blood Glucose Date

Have You Ever Had A Mammogram: Yes  No    Date

Have You Ever Had A Bone Density Scan:  Yes  No    Date

List All Past Medical Conditions:

Dietary And Social Information:

Breakfast Foods:    

Lunch Foods:     

Dinner Foods:        

Snack Foods:    

Do You Drink? Yes  No    If yes, what and how often:

Do You Smoke? Yes  No  If yes, what and how often:

Do You Use Drugs? Yes  No  What and how often:    

Do You Exercise?  Yes  No   If yes, please explain:     

Family Medical History:

Father Living  Deceased  Age Medical History

Mother Living  Deceased  Age  Medical History

Sibling  Living  Deceased  Age  Medical History

Sibling  Living  Deceased  Age  Medical History

Sibling  Living  Deceased  Age  Medical History

Gynecological History

Age at first period     Date of last period

Date of last pelvic exam & pap smear

Results

Are you sexually active? Yes    No

Are you trying to get pregnant?  Yes    No

Current birth control method, if applicable

Problems associated with birth control, if applicable

How many days from the start of one period to the start of the next?

Number of days of flow   Amount of bleeding Select Light Medium Heavy

Premenstrual Symptoms (List Starting Days)

Any current changes in your normal cycle?

Any bleeding between periods?  Yes    No    Explain

Any pelvic pain or pressure?    Yes    No    Explain

Any unusual vaginal discharge?    Yes    No    Explain

Age at first pregnancy     How many full term pregnancies?

Have you experienced any problem pregnancies? Yes    No

Explain

Have you had a tubal ligation?  Yes    No

Have you had any part or whole ovary removed?  Yes    No      When

Have you had a hysterectomy? Yes    No    Select If Yes Partial Complete     When

List Of Symptoms

Headaches: Absent    Mild    Moderate    Severe

Low Libido:    Absent    Mild    Moderate    Severe

Anxiety:    Absent    Mild    Moderate    Severe

Swollen Breasts:    Absent    Mild    Moderate    Severe

Moodiness:    Absent    Mild    Moderate    Severe

Fuzzy Thinking:    Absent    Mild    Moderate    Severe

Depression:    Absent    Mild    Moderate    Severe

Food Cravings:    Absent    Mild    Moderate    Severe

Irritability:    Absent    Mild    Moderate    Severe

Insomnia:    Absent    Mild    Moderate    Severe

Cramps:    Absent    Mild    Moderate    Severe

Emotional Swings:    Absent    Mild    Moderate    Severe

Painful Breasts:    Absent    Mild    Moderate    Severe

Weight Gain:    Absent    Mild    Moderate    Severe

Bloating:    Absent    Mild    Moderate    Severe

Low Concentration:    Absent    Mild    Moderate    Severe

Hot Flashes:    Absent    Mild    Moderate    Severe

Difficulty Breathing:    Absent    Mild    Moderate    Severe

Vaginal Dryness:    Absent    Mild    Moderate    Severe

Dry Hair/Skin:    Absent    Mild    Moderate    Severe

Memory Loss:    Absent    Mild    Moderate    Severe

Urinary Infections:    Absent    Mild    Moderate    Severe

Heart Palpitations:    Absent    Mild    Moderate    Severe

Yeast Infections:    Absent    Mild    Moderate    Severe

Painful Intercourse:    Absent    Mild    Moderate    Severe

No Orgasm:    Absent    Mild    Moderate    Severe

Water Retention:    Absent    Mild    Moderate    Severe

Fatigue:    Absent    Mild    Moderate    Severe

Fibrocystic Breasts:    Absent    Mild    Moderate    Severe

Heavy Menses:    Absent    Mild    Moderate    Severe

Irregular Menses:    Absent    Mild    Moderate    Severe

Uterine Fibroids:    Absent    Mild    Moderate    Severe

Sweet Cravings:    Absent    Mild    Moderate    Severe

Weight Gain:    Absent    Mild    Moderate    Severe

Low Thyroid:    Absent    Mild    Moderate    Severe

Please feel free to add any additional information concerning any of the above symptoms in the space below.  Be as descriptive as possible.

Would you like to have our office call you for a private and personal hormone evaluation with a compounding pharmacist specializing in Natural "Bio-Identical" Hormone Replacement?

Yes   No

What time of the day would you like us to contact you?

Morning   Afternoon  Evening

What specific questions do you have for our Hormone Specialist? Our FREE response will be e-mailed back to you in a timely manner.

Would you like a FREE recommendation on which hormones to have tested based on the information provided in this evaluation?

Yes        No

CLICK HERE TO SUBMIT DATA       

This free bio-identical hormone replacement evaluation is provided by

TestMyHormones.com.  All data and information collected is considered

confidential and will not be distributed without patent consent.