Comprehensive Hormone Intake and Health History Form

Instructions:
Please complete this form to provide a comprehensive history of your health, hormone use, and lifestyle. Answer each question to the best of your ability. If a question does not apply to you, please mark N/A.


Home Address (address, city, state, zip code)*
Primary Care Physician (name and clinic)*
Marital Status: *
Do you have a latex allergy?*
Have you ever had issues with local anesthesia?*
Current or past hormone therapy?*
Sexual Health History (Select all that apply)*
Tobacco Use (Select all that apply)*
Alcohol Use*
Caffeine Use*
Family Health History (Select all that apply)*
Birth Control Method (Select all that apply)*
Medical/Surgical History (Select all that apply)*
Female-Specific Health History (Select all that apply)*
Male-Specific Health History (Select all that apply)*
Activity Level (Select one)*
Anything else you want us to know?