Hormone Intake Form


Date of Birth (mm/dd/yyyy)*
Current Weight*
Occupation*
Home Address (address, city, state, zip code)*
Primary Care Physician ( name and clinic)*
Marital status*
Allergies*
Do you have a latex allergy?*
Have you ever had issues with local anesthesia*
Current or past hormone therapy?*
Current medications*
Sexual Health History (select all that apply)*
Current Tobacco Use (select all that apply)*
Alcohol Use*
Caffeine Use*
Family Health History (select all that apply)*
Pertinent Hormone Health History (select all that apply)*
Birth Control Method (select all that apply)*
Medical History (select all that apply)*
Anything else you want us to know?