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Turn on this switch, Male Hormone Consult
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Turn on this switch, Female Hormone Consult
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May we contact you via E-Mail
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Marital Status
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Please click on FREEDRAW
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Spouse’s Name
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Relationship
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Home Phone
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Cell Phone
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Work Phone
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Social
• • •
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Habits
• • •
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I smoke cigarettes or cigars__a day.
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I drink alcoholic beverages__a day
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I use caffeine__a day.
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Medical History
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Any known drug allergies?
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Have you ever had any issues with anesthesia
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If yes please explain
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Medications Currently Taking
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Current Hormone Replacement Therapy
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Past Hormone Replacement Therapy
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Nutritional/Vitamin Supplements
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Surgeries, list all and when
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Other Pertinent Information
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Preventative Medical Care
• • •
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High Risk Past Medical/Surgical History
• • •
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Medical Illnesses
• • •
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Cancer?
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Type/Year
/
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May we contact you via E-Mail
|
Marital Status
|
|
Please click on FREEDRAW
|
|
|
Spouse’s Name
|
Relationship
|
|
Home Phone
|
Cell Phone
|
|
Work Phone
|
|
|
Social
• • •
|
Habits
• • •
|
|
I smoke cigarettes or cigars__a day.
|
I drink alcoholic beverages__a day
|
|
I use caffeine__a day.
|
|
|
Medical History
|
|
|
Any known drug allergies?
|
|
|
Have you ever had any issues with anesthesia
|
If yes please explain
|
|
Medications Currently Taking
|
Current Hormone Replacement Therapy
|
|
Past Hormone Replacement Therapy
|
Nutritional/Vitamin Supplements
|
|
Surgeries, list all and when
|
|
|
Last menstrual period
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<-- (estimate year if unknown)
|
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Other Pertinent Information
|
|
|
Preventative Medical Care
• • •
|
High Risk Past Medical/Surgical History
• • •
|
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Birth Control Method
• • •
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Other
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Medical Illnesses
• • •
|
|
|
Cancer?
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Type/Year
/
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