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Hormone Replacement Therapy Consultation
Note: HRT consult is subject to a $250 fee & HRT lab fee is $200
Desired Location
Minneapolis
San Antontio
First Name &
Last Name
Date of Birth
Phone Number
Phone
Email
Adress
Gender
Male
Female
Non-Binary
Trans Woman
Trans Man
Ethnicity *
African American
Asian
Caucasian/White
Hispanic
Middle Eastern
Native American
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
Birth Control Method
Hysterectomy
Tubal Ligation
Vasectomy
IUD
Oral Pill
Implant
None
Sexual Activity *
I am sexually active
I want to be sexually active
I want to increase my sexual activity
I have completed my family
My sex has suffered
I haven't been able to have an orgasm
List All Medications
List Previous/Current Hormone Replacement Therapy(include years)
List Any Medication Allergies
Symptoms
Lack of Energy / Fatigue
Mild
Never
Moderate
Severe
Mood Changes / Anxiety
Mild
Never
Moderate
Severe
Decreased Mental Focus / Memory
Mild
Never
Moderate
Severe
Difficulty Sleeping at Night
Mild
Never
Moderate
Severe
Decreased Sex Drive
Mild
Never
Moderate
Severe
Weight Gain
Mild
Never
Moderate
Severe
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