Name *

First

Last

Contact Number *

Email *

Hot flashes, sweating? *

(episodes of sweating)

Heart discomfort *

(unusual awareness of heart beat, heart skipping, heart racing, tightness)

Sleep problems *

(difficulty in falling asleep, difficulty in sleeping through the night, waking up early)

Depressive mood *

(feeling down, sad, on the verge of tears, lack of drive, mood swings)

Irritability *

(feeling nervous, inner tension, feeling aggressive)

Anxiety *

(feeling panicky)

Physical and mental exhaustion *

(general decrease in performance, impaired memory, decrease in concentration, forgetfulness)

Sexual problems *

(change in sexual desire, n sexual activity and satisfaction)

Bladder problems? *

(difficulty in urinating, increased need to urinate, bladder incontinence)

Dryness of vagina *

(sensation of dryness or burning in the vagina, difficulty with sexual intercourse)

Joint and muscular discomfort *

(pain in the joints, rheumatoid complaints)

Do you have cold hands and feet? *

Do you have daily bowel movements? *

Do you have gas, bloating or abdominal pain after eating? *

Please select your WEEKLY Activity Level based on this criteria *

Physical activity that accelerates heart rate / Breathlessness

Please share any additional comments about your symptoms you would like to address.

Please list any prior hormone therapy?

Fee Acknowledgement *

Yes

Although more insurance companies are reimbursing patients for Bio-Identical Hormone Replacement Therapy, there is no guarantee. You will be responsible for payment in full at the time of your BHRT procedure (see fee schedule below). New Patient Consultation Fee (free for members) $150. Female Hormone Pellet Insertion Fee $350

Chart ID

Office Use Only

DOB

Office Use Only

APP Date?

Office Use Only

HRT Female Checklist

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