Female Hormone Registration FormPersonal DataFirst Name *Middle NameLast Name *Email Address *Home PhoneWork/Cell PhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDate of Birth *HeightWeightEmployerEmergency ContactEmergency PhoneMarital StatusMarriedWidowedSeparatedDivorcedSingleOtherPrimary Care PhysicianNamePhone/FaxStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePresent SymptomsPlease briefly describe your symptoms.What do you feel is the most important factor to your present symptoms?Past Medical HistoryPlease list dates and diagnoses, illnesses, accidents (1 per line).Please list dates and surgeries (1 per line).Social HistoryPlease remember that this information is strictly confidential and will be used only to address you symptoms and/or complaints.Do you smoke cigarettes now? If yes, how many packs per day?Have you smoked in the past? If yes, how many total years have you smoked?Do you drink alcohol? If yes, how many drinks and what type of alcohol (beer, wine, spirits, etc.) do you have in an average week?Family HistoryPlease 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.MotherFatherBrother(s)Sister(s)ChildrenSpouseMedicationsPlease list ALL prescription medications. Include ALL over the counter medications, supplements, and vitamins.MedicationsAllergiesAre you allergic to any MEDICATIONS (Prescription or OTC)?Gynecological HistoryLast PAP smearPhysicianPhysician's phoneLast mammogramFacilityFacility's phoneHave you ever had an abnormal PAP smear? If yes, what was the abnormality and what follow up did you have?Have you ever had an abnormal mammogram? If yes, what was the abnormality and what follow up did you have?Have you ever had a breast biopsy? If yes, how many breast biopsies (positive or negative) have you had?Check all that apply.Have you had at least one breast biopsy with atypical hyperplasia?Do you have a medical history of any breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS) or have received radiation therapy to the chest for treatment of Hodgkin lymphoma?Have you ever had a cervical biopsy?Have you noticed any lumps in your breasts?Have you been tested and been told you have the BRAC1 or BRAC2 gene, or a diagnosis of a genetic syndrome that may be associated with increased risk of breast cancer? Are you still having menstrual periods? If yes, when was the first day of your last period?Please describe any problems you have with your periods.What was your age at the time of your 1st menstrual cycle?What was your age at the time of your 1st menstrual cycle?Number of daysTotal cycle lengthIf you are no longer having periods, at what age did your periods stop?If your periods stopped less than one year ago, how many months ago was your last period?Did your periods stop because you had a hysterectomy? If yes, what was the reason for the surgery?Were the ovaries removed at the same time?Do you have a history of any of the following cancers?VulvaUterusVaginaCervixOvaryFallopian TubeBreastColonOther cancerHormone Therapy HistoryHave you been treated with any hormone replacement therapy? If yes, please give approximate periods of treatment.Present SymptomsEstrogen DeficiencyHot FlashesNight SweatsVaginal DrynessFoggy ThinkingMemory LapsesUrinary IncontinenceTearfulDepressedSleep DisturbancesHeart Palpitations/ArrhythmiaBone LossHeadachesCheck which of these symptoms are troublesome and have persisted over time:Estrogen Excess / Progesterone DeficiencyMood Swings (PMS)Cystic OvariesTender BreastsHeavy MensesWater RetentionSugar CravingsNervousnessIrritabilityAnxiousFibrocystic BreastHeadachesCold Body TemperatureUterine FibroidsWeight Gain – Hip AreaBleeding ChangesElevated TriglyceridesBreast CancerLow LibidoAndrogen DeficiencyLow LibidoVaginal DrynessFatigueAches/PainsMemory LapsesFoggy ThinkingUrinary IncontinenceDepressedAnxiousBone LossSleep DisturbancesApathy/Decreased Passion for LifeDecreased Muscle MassHeart Palpitations/ArrhythmiaHeadachesFibromyalgiaIrritableThinning SkinAndrogen ExcessIncreased Facial HairIncreased Body HairAcneOily SkinNervousIrritableAnxiousBreast CancerOvarian CystsElevated TriglyceridesSleep DisturbancesThyroid DeficiencyCold IntoleranceConstipationFatigue/WeaknessUnexplained Weight GainInability to Lose WeightCold Body TemperatureLack of MotivationAches/PainsHair LossMuscle WeaknessMuscle CrampsStressCoarse Dry SkinThyroid ExcessHeat IntoleranceIrritableHeart Palpitations/ArrhythmiaWeight LossTremors/ShakinessDiarrheaNervousness/Anxious/Panic AttacksInsomniaDifficulty Conceiving/InfertilitySend Form
