HORMONE THERAPY FORM

Please complete our online intake form below.

This allows our doctor to review your file and approve you for any prescription deemed safe and appropriate for your weight loss and health needs.

Our medical team will contact you within a few days to discuss the way forward.

First Name(Required)

Last Name(Required)

Gender(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone No(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Emergency Contact Relationship(Required)

Primary Doctor's Name

Primary Doctor's Contact No

What is your weight? (Kg)

What is your height? (cm)

Do you have a personal history with any of the following?

Breast Cancer

Uterine Cancer

Ovarian Cancer

Prostate Cancer

Thromboembolic Event (Blood Clot)

Thromboembolic Disorder

Coronary Heart Disease

Myocardial Infarction (Heart Attack)

Please list any other medical conditions you've been diagnosed with.

Are you under a doctor's care at the present time?

Yes

What are the goals you hope to achieve with hormone therapy?

Surgeries & Other Hospitalisations

1. Reason / Diagnosis

Hospital

Year

2. Reason / Diagnosis

Hospital

Year

3. Reason / Diagnosis

Hospital

Year

Allergies to Medication

Please list any medications you have known allergies to:

1. Medication Name

Purpose

Reaction

2. Medication Name

Purpose

Reaction

3. Medication Name

Purpose

Reaction

Do you take any medication for depression, anxiety or mood related conditions?

Yes

If yes - what to do you take?

Have you had any history of any mental health condition and taken any medication in the past?

Yes

Does any immediate family have any mental health conditions?

Yes

List any prescribed medications, over-the-counter drugs, dietary supplements (include vitamins, inhalers, etc.)

1. Medication Name

Dose

Frequency

2. Medication Name

Dose

Frequency

3. Medication Name

Dose

Frequency

4. Medication Name

Dose

Frequency

5. Medication Name

Dose

Frequency

Marital Status

Employment Status

How many meals do you consume a day?

How would you describe your diet?

How often do you exercise?

How many hours do you sleep a night?

Do you take sleeping aids?

Yes

What Types of Caffeine Do You Drink?

Coffee

Tea

Soda

None

How Many Cups/Cans Per Day?

Do You Drink Alcohol?

Yes

How Often?

Do You Smoke?

Yes

How Many Cigarettes Per Day?

For How Many Years?

Did You smoke in the past?

Yes

When did you stop?

Are you currently sexually active?

Yes

Are you in a committed, mutually monogamous relationship?

Are you trying to get pregnant?

Yes

If not, do you practice safe sex?

Yes

If yes, list contraceptive / barrier method

Please select all of the following that apply:

Decline in your feeling of general well-being

Difficulty concentrating

Memory problems

Physical exhaustion/Lacking vitality (General decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, having to force oneself to undertake activities)

Low energy, often feeling tired and fatigued

Increased need for sleep

Sleep problems (Difficulty in falling and or staying asleep)

Weight gain

Difficulty losing weight

Decrease in muscular strength (Feeling of physical weakness)

Joint pains and/or muscle aches

Depressed mood (Feeling down, sad, on the verge of tears, lack of drive/motivation)

Anxiety (Feeling panicky)

Nervousness (Inner tension, restlessness, feeling fidgety)

Irritability (Feeling aggressive, easily upset by little things, moody)

Mood swings

Emotional

Females Only

How would you describe your current menstrual status?

Age at first menstrual period?

Approximate date of your last menstrual period?

Are your periods usually regular?

How often do they usually occur?

How many days does your period usually last?

If you no longer having periods, at what age did you have your last period?

If you no longer having periods, Was your menopause?

Do you have a cervix?

Yes

Do you have a uterus?

Yes

Do you have both ovaries?

Yes

History of abnormal results?

When was your last mammogram?

Please indicate method of birth control

Have you been pregnant?

Please select all that apply

Hot flashes

Night sweats

Irregular periods

Shorter cycles

Longer cycles

Lighter periods

Heavier periods

Spotting or bleeding between periods

Painful periods

Abnormal vaginal bleeding after menopause

PMS (including but not limited to mood swings, bloating, cramping, breast tenderness, and/or headaches prior to period)

Decrease in sexual interest/ desire/ libido (lacking pleasure in sex, lacking desire for sexual intercourse)

Loss of sexual response (weaker or absent orgasm)

Vaginal dryness

Pain during intercourse

More frequent urinary tract/bladder infections

Incontinence

Frequent urination

Excessive urination

Vaginal itching

Abnormal vaginal discharge

Increased vaginal infections

Males Only

When was your last PSA level tested?

Any elevated results?

If yes, when?

When was your last prostate exam?

Any abnormal findings, if yes what?

Please select all that apply

Frequent urination throughout the night

Decreased force of urination

Feeling of incomplete emptying of bladder after urination

More frequent urinary tract/bladder infections

Decrease in sexual interest / desire / libido (lacking pleasure in sex, lacking desire for sexual intercourse?

Feeling that you have passed your peak sexually

Decrease in ability and / or frequency to perform sexually

Decrease in the number of morning erections

Difficulty obtaining / maintaining an erection

Loss of sexual response / ejaculation (weaker or absent orgasm)

Consent(Required)

Agreement to our terms and conditions

I have read and agree to the content of this consent document

Phone

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