Have you ever had hormone therapy? (*)
What are your top three goals for starting Hormone Replacement Therapy? (*)
Are you currently taking any other than those for Hormone/Testosterone Therapy? if so, list each medication, dosage and frequency below
Have you had a prostate exam? (*)
Have you had a recent wellness/physical exam? (*)
Have you been diagnosed with prostate cancer? (*)
Have you been diagnosed with breast cancer? (*)
Have you had prostate enlargement? (*)
Have you had any form of cancer? (*)
Do you use any anti-coagulations or blood thinners other than aspirin? (*)
Do any of the following apply?
Have you noticed a decrease in your sex drive? (*)
Have you noticed a decrease in energy levels? (*)
Do you feel weaker or have less stamina? (*)
Do you feel tired all the time? (*)
Have you noticed decreased work performance? *
Are you more lethargic after dinner? (*)
Are your erections less hard? (*)
Are you prone to sadness or anger? (*)
Has your height diminished? (*)
Are you suffering from less vitality? (*)
Any family history of Thyroid Cancer? (*)
Have you had a recent wellness/physical exam?
Have you had any of the following types of cancer?
Ovarian
Uterine
Breast Cancer or Suspicion
Cervical
Any form of cancer
Are you Currently Pregnant? (*)
Do you plan to have more children? (*)
Are you Currently Breastfeeding? (*)
Are you currently sexually active? (*)
Hot flashes (*)
Mood swings (*)
Vaginal dryness (*)
Headache / Fatigue (*)
Painful intercourse (*)
Short term memory or memory concerns (*)
Decreased sex drive (*)
Dry skin (*)
Water retention (*)
Bone mineral loss (Osteoporosis) (*)
Fat, especially hips, thighs, and abdomen (*)
Diffuse Body Pain/Aches (*)
Sleep disturbances (*)
Date of last period
Date of last period How many days does your period last?
Are you taking any form of Birth Control? If Yes, please list it (*)
Do you have heavy cycles? If Yes, please explain.
Do you have regular cycles? If No, please explain.
Do you take any medications or supplements to address any issues with menstruation? If Yes, please explain.
Do you use any anti-coagulations or blood thinners othen than aspirin? If Yes, please explain.
Any family history of Thyroid Cancer? If Yes, please explain.
Have you have had a mammogram, when was your last one?
What were your results?
Head Trauma
Cancer of any type
Heart disease or any heart related issues
HIV or related disease
High blood pressure
Immune deficiency of any type
Strokes
Skin disorders
Poor Circulation
Muscular or bone disorders
Edema or Swelling
Arthritis or autoimmune disorders
High Cholesterol
Disorder of the nervous system
Hormonal imbalance of any type
Seizure disorder
Sleep Apnea
Psychiatric disorders
Lung disorders
Psychiatric Hospitalizations
Clotting disorders
Depression
Digestive disorders
Vision disorders
Liver disorders
Hearing disorders
Hepatitis of any type
Upper respiratory, sinus disorders
Diabetes
Excessive snoring
Kidney disorders
Contagious condition
Bladder disorders
Illnesses contracted while abroad
Testicular or genital problems
Life threatening conditions
Physical defect or deformity
Genetic Disorders