Female Hormone Patient Information

Personal Data

 
Wilmington, NC
Goldsboro, NC

Primary Care Physician

Present Symptoms

Past Medical History

Social History

Please remember that this information is strictly confidential and will be used only to address you symptoms and/or complaints.

 
 
 

Family History

Please list ALL illness(heart disease, stroke, diabetes, hypertension, cancer (breast, cervical, skin, prostate, lung, blood), etc. If a member is deceased, please list age of death and cause if known.

Medications

Please list ALL prescription medications. Include ALL over the counter medications, supplements, and vitamins.

Allergies

Gynecological History

 
 
 
 
 
Were the ovaries removed at the same time?
 
Vulva
Uterus
Vagina
Cervix
Ovary
Fallopian Tube
Breast
Colon

Hormone Therapy History

Present Symptoms

Check which of these symptoms are troublesome and have persisted over time:
Hot Flashes
Night Sweats
Vaginal Dryness
Foggy Thinking
Memory Lapses
Urinary Incontinence
Tearful
Depressed
Sleep Disturbances
Heart Palpitations/Arrhythmia
Bone Loss
Headaches
Mood Swings (PMS)
Cystic Ovaries
Tender Breasts
Heavy Menses
Water Retention
Sugar Cravings
Nervousness
Irritability
Anxious
Fibrocystic Breast
Headaches
Cold Body Temperature
Uterine Fibroids
Weight Gain – Hip Area
Bleeding Changes
Elevated Triglycerides
Breast Cancer
Low Libido
Low Libido
Vaginal Dryness
Fatigue
Aches/Pains
Memory Lapses
Foggy Thinking
Urinary Incontinence
Depressed
Anxious
Bone Loss
Sleep Disturbances
Apathy/Decreased Passion for Life
Decreased Muscle Mass
Heart Palpitations/Arrhythmia
Headaches
Fibromyalgia
Irritable
Thinning Skin
Increased Facial Hair
Increased Body Hair
Acne
Oily Skin
Nervous
Irritable
Anxious
Breast Cancer
Ovarian Cysts
Elevated Triglycerides
Sleep Disturbances
Cold Intolerance
Constipation
Fatigue/Weakness
Unexplained Weight Gain
Inability to Lose Weight
Cold Body Temperature
Lack of Motivation
Voice has become hoarse
Aches/Pains
Hair Loss
Muscle Weakness
Muscle Cramps
Stress
Coarse Dry Skin
Heat Intolerance
Irritable
Heart Palpitations/Arrhythmia
Weight Loss
Tremors/Shakiness
Diarrhea
Nervousness/Anxious/Panic Attacks
Insomnia
Difficulty Conceiving/Infertility
 

 

*Individual results may vary.