HRT Patient Intake Questionnaire
Please complete this form to help us understand your health background and suitability for Hormone Replacement Therapy.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Assigned Sex at Birth
*
Female
Male
Intersex
Other
Gender Identity
*
Woman
Man
Non-binary
Other
Please indicate if you have experienced or been diagnosed with any of the following conditions:
*
High blood pressure
Heart disease
Blood clots
Cancer
Liver disease
Diabetes
Thyroid disorders
None of the above
Other
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Hot flashes or night sweats
Mood changes or depression
Fatigue
Decreased libido
Sleep disturbances
Vaginal dryness (if applicable)
Erectile dysfunction (if applicable)
Memory or concentration issues
None of the above
Other
Please list any current medications, supplements, or herbal remedies you are taking.
*
Do you have any allergies? If yes, please list them.
*
Lifestyle Factors
*
Rows
Yes
No
Do you smoke?
1
2
Do you consume alcohol?
3
4
Do you exercise regularly?
5
6
Please indicate if any of your immediate family members have a history of the following conditions:
Breast cancer
Ovarian cancer
Prostate cancer
Heart disease
Diabetes
None of the above
Other
Is there anything else you would like your provider to know regarding your health or goals for HRT?
Please sign below to confirm the information provided is accurate to the best of your knowledge.
*
Submit
Submit
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