|
LMP (MM/DD/YYYY)
|
Hysterectomy
|
|
Ovariectomy
|
If PT has had ovariectomy, when?
|
|
Gravida/Para
/
|
Breast Status
• • •
|
|
Family Hx of breast CA
|
Previously on HRT
|
|
If previously on HRT, When
|
If previously on HRT, What
|
|
If previously on HRT, outcome
|
|
|
Document Associated Sx
|
|
|
Decreased Libido
|
Vaginal Dryness
|
|
Poor Sleep
|
Mood Swings
|
|
Hot Flashes
|
Sweats
|
|
Dry Skin
|
Thinning Hair
|
|
Fat Gain
|
Most Recent Lab Values
|
