Female BHRT Questionnaire

Full Name *

Current Age *

Date of birth *

Weight (lbs) *

Height (ft/in) *

Ethnicity (check one): *

Caucasian

African-American

Hispanic

Middle Eastern

Asian

Native American

Other

Medical History

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 list 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

Assessment Data

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?

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