Consulta de Terapia de Reemplazo Hormonal

Consulta de Terapia de Reemplazo Hormonal”

Desired Location

Minneapolis San Antontio

First Name &

Last Name

Date of Birth

Phone Number

Phone

Email

Adress

Height (feet)

Height (inches)

Height (Pounds)

Heaviest Weight You've Ever Been

Do You Smoke

Yes No

List Past & Ongoing Medical History

List Any Personal & Family Cancer History(include years)

List Any/All Surgical History(include years)

List Number of Pregnancies(WOMEN ONLY)

List Number of Children(WOMEN ONLY)

In The Last 12 months, Check That Apply(WOMEN ONLY) *

Gynecological Exam Mammogram Bone Density Pelvic Ultrasound

Sexual Activity *

List All Medications

List Previous/Current Hormone Replacement Therapy(include years)

List Any Medication Allergies

Symptoms

Lack of Energy / Fatigue

Mood Changes / Anxiety

Decreased Mental Focus / Memory

Difficulty Sleeping at Night

Decreased Sex Drive

Weight Gain

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Total Reviews

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Average Rating

Consulta de Terapia de Reemplazo Hormonal

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