Female BHRT Questionnaire

Ethnicity (check one): *

Do you have a history of breast cancer? *

Yes

Do you have a history of fibrocystic breast disease? *

Yes

Are you currently on birth control? *

Yes

If yes, please select the type:

Have you ever had a hysterectomy? *

Yes

If yes, please specify (partial, total, etc.):

Do you have (or have you ever been diagnosed with) PCOS? *

Yes

Uncertain

What is your smoking history? *

Current smoker

Former smoker

Never smoked

If current or former, how many years?

Do you have a history of adult acne? *

Yes

Are you currently on testosterone therapy? *

Yes

Are you currently on estrogen therapy? *

Yes

Have you ever been on estrogen therapy in the past? *

Yes

If yes, how long ago and for how long?

Are you still having menstrual cycles? *

No menstrual cycle (≥12 months since last menstrual period / LMP)

Regular

Irregular (perimenopause)

Irregular (birth control, PCOS, other)

If "No menstrual cycle" (>12 months since last menstrual period/LMP):

LMP <= 10 years ago

LMP > 10 years ago

N/A

Have you ever had a mammogram? *

Yes

If yes, was it normal or abnormal? Please explain:

Are you currently taking ADD/ADHD medications (Adderall, Concerta, Vyvanse, etc.)? *

Yes

Are you a chronic pain patient? *

Yes

Would you describe your activity level as high, average, or low? *

High

Average

Low

Do you experience headaches or migraines during your menstrual cycle? *

Yes

N/A - no menstrual cycles

Are you experiencing hot flashes or nighttime sweating? *

Yes

Have you had vaginal dryness, urinary tract infections, or other urogenital problems? *

Yes

Are you experiencing low sexual desire? *

Yes

Do you often feel fatigued or unusually tired? *

Yes

Are you experiencing unexplained weight gain? *

Yes

Do you experiencing trouble with focus, memory, or mental clarity? *

Yes

Are you having problems sleeping? *

Yes

Have you been experiencing depression, anxiety, or fatigue? *

Yes

Do you have aches or discomfort in your joints or muscles? *

Yes

Any Additional Comments, Questions Or Special Requests?

I agree to the Terms & Conditions provided by Alma Rx Clinic. By providing my phone number and/or email, I agree to be contacted by Alma Rx Clinic for purposes related to my care, appointments, or treatment.