Confidential Female Hormone Evaluation

    Allergies: Please list any allergies and describe the reaction that occurred

    Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):

    Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from.
    (Examples include: Heart diseases, high blood pressure, depression, ulcers, arthritis, insomnia, etc).

    Current Prescription Medications (including hormones):

    Have you had any of the following tests performed?

    Absent

    Mild

    Moderate

    Severe

    Hot Flashes

    Client comment:

    RPH Notes:

    Night Sweats:

    Client comment:

    RPH Notes:

    Vaginal Dryness:

    Client comment:

    RPH Notes:

    Incontinence:

    Client comment:

    RPH Notes:

    Bleeding Changes:

    Client comment:

    RPH Notes:

    Fibrocystic Breast:

    Client comment:

    RPH Notes:

    Weight Gain:

    Client comment:

    RPH Notes:

    Fluid Retention:

    Client comment:

    RPH Notes:

    Dry Skin/Hair:

    Client comment:

    RPH Notes:

    Dry Skin/Hair:

    Client comment:

    RPH Notes:

    Anxiety:

    Client comment:

    RPH Notes:

    Depression:

    Client comment:

    RPH Notes:

    Mood Swings:

    Client comment:

    RPH Notes:

    Irritability:

    Client comment:

    RPH Notes:

    Headaches:

    Client comment:

    RPH Notes:

    Breast Tenderness:

    Client comment:

    RPH Notes:

    Cramps:

    Client comment:

    RPH Notes:

    Difficulty Falling Asleep:

    Client comment:

    RPH Notes:

    Difficulty Staying Asleep:

    Client comment:

    RPH Notes:

    Fatigue:

    Client comment:

    RPH Notes:

    Loss of Memory:

    Client comment:

    RPH Notes:

    Foggy Thinking:

    Client comment:

    RPH Notes:

    Acne:

    Client comment:

    RPH Notes:

    Arthritis:

    Client comment:

    RPH Notes:

    Decreased Sex Drive:

    Client comment:

    RPH Notes:

    Harder to Reach Climax:

    Client comment:

    RPH Notes:

    Stress:

    Client comment:

    RPH Notes:

    Other:

    Doctor that we should contact for this therapy:

    address