Hormone Replacement Therapy Consultation
Note: HRT consult is subject to a $250 fee & HRT lab fee is $200
Desired Location
Minneapolis
San Antontio
Legal First & Last Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Non-Binary
Trans Woman
Trans Man
Ethnicity
*
African American
Asian
Caucasian/White
Hispanic
Middle Eastern
Native American
Height (feet)
*
Height (inches)
*
Weight (pounds)
*
Heaviest Weight You've Ever Been
*
Do You Smoke
*
Yes
No
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 Exam
Mammogram
Bone Density
Pelvic Ultrasound
Birth Control Method
*
Hysterectomy
Tubal Ligation
Vasectomy
IUD
Oral Pill
Implant
None
Sexual Activity
*
I am sexually active
I want to be sexually active
I want to increase my sexual activity
I have completed my family
My sex has suffered
I 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
Never
Mild
Moderate
Severe
Mood Changes / Anxiety
Never
Mild
Moderate
Severe
Decreased Mental Focus / Memory
Never
Mild
Moderate
Severe
Difficulty Sleeping at Night
Never
Mild
Moderate
Severe
Weight Gain
Never
Mild
Moderate
Severe
Decreased Sex Drive
Never
Mild
Moderate
Severe
Submit
Should be Empty: