Hormone Replacement Therapy Consultation

Hormone Replacement Therapy Consultation

Note: HRT consult is subject to a $250 fee & HRT lab fee is $200
Desired Location

MinneapolisSan Antontio
Legal First & Last Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemaleNon-BinaryTrans WomanTrans Man
Ethnicity *

African AmericanAsianCaucasian/WhiteHispanicMiddle EasternNative American
Height (feet) *
Height (inches) *
Weight (pounds) *
Heaviest Weight You've Ever Been *
Do You Smoke *

YesNo
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 ExamMammogramBone DensityPelvic Ultrasound
Birth Control Method*

HysterectomyTubal LigationVasectomyIUDOral PillImplantNone
Sexual Activity *

I am sexually activeI want to be sexually activeI want to increase my sexual activityI have completed my familyMy sex has sufferedI haven't been able to have an orgasm
List All Medications *
List Prescription & OTC Vitamins/Supplements
List Previous/Current Hormone Replacement Therapy(include years) *
List Any Medication Allergies *
Symptoms
Lack of Energy / Fatigue
Mood Changes / Anxiety
Decreased Mental Focus / Memory
Difficulty Sleeping at Night
Weight Gain
Decreased Sex Drive
Should be Empty:

Hormone Replacement Therapy Consultation

Symptoms