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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*
Single
Married
Divorced
Widowed
Living with partner
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)*
I am sexually active
I have completed my family
My sex life has suffered
I want to be sexually active
I have NOT completed my family
I have not been able to have an orgasm or it is very difficult
I do not want to be sexually active
Current Tobacco Use (select all that apply)*
I smoke cigarettes or cigar
I use e-cigarettes
I quit smoking
I do not use any tobacco products
Alcohol Use*
I do not drink alcohol
I drink 1-3 beverages per week
I drink 4-6 beverages per week
I drink 7-10 beverages per week
I drink more than 10 beverages per week
Caffeine Use*
I do not consume caffeine products
I drink 1-3 caffeinated beverage per day
I drink 3 or more caffeinated beverage per day
Family Health History (select all that apply)*
Heart disease
Diabetes
Osteoporosis
Alzheimer's/Dementia
Breast Cancer
Pertinent Hormone Health History (select all that apply)*
Breast Cancer
Uterine Cancer
Ovarian Cancer
PCOS
Acne
Excess facial/body hair
Infertility
Endometriosis
Seizures
Fibrocystic breast or breast pain
Uterine Fibroids
Irregular or heavy periods
Menstrual migraines
Hysterectomy with removal of ovaries
Partial Hysterectomy (uterus only)
Oophorectomy removal of ovaries only
Birth Control Method (select all that apply)*
Menopause
Hysterectomy
Tubal Ligation
Birth Control Pills
IUD (hormone)
IUD (hormone free)
Vasectomy
Medical History (select all that apply)*
High blood pressure
Heart disease
A-fib or other arrhythmia
Blood clot and/or pulmonary embolism
Depression/anxiety
Chronic liver disease
Arthritis
Hair thinning
High Cholesterol
Stroke and or heart attack
HIV or any type of hepatitis
Herpes
Hemochromatosis
Psychiatric disorder
Thyroid disease
Diabetes
Autoimmune disease
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Mia Hartman
USA
8022724631
•
nphartman.22@gmail.com
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