Human Hormone Replacement
Confidential Symptom Survey
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PLEASE PRINT OUT THIS FORM, FILL IT OUT, AND MAIL IT TO US ALONG WITH YOUR COMPLETELY FILLED OUT GENERAL CONSULTATION FORM
Click here for the General Consultation Form

Lionville Natural Pharmacy
309 Gordon Drive
Lionville, PA 19341
Phone: 610-363-7474 Fax: 610-363-5707

Ben Briggs, RPh, CNC, IACP

From a clinical management point of view, it is very useful to gain a detailed history of possible hormone deficiencies. The answers provided in the questions below will allow the pharmacist to maintain your medical history and will help in advising about current medical therapies. All information provided will be kept confidential.

GENERAL INFORMATION Date: ____________

Name: _________________________________________ Age: _________ Birth Date: __________

Street Address: __________________________________________________________ Apt. ___________

City: ___________________________________________ State: _________ Zip: __________

Occupation: ____________________________ Full-Time Part-Time Retired Unemployed Other

Telephone number: Day: _____________________________ Evening: __________________________

Living Situation: Spouse Alone Partner Friend(s)Parents Children Other

Status: Married Single Divorced Widowed

How did you hear about Natural Hormone Replacement Therapy?: Ad Another Patient Friend Physician/Health PractitionerBooks/Articles Class/Seminar Other

If you had a referral, who referred you?: _______________________________________________________

Have you discussed HRT with your Health Care Practitioner?: ____________________________________________________

Do you understand what Natural Hormone Replacement is?: _______________________________________________________

What are your three main symptoms/concerns?:

1. _________________________________________________________ Since when?: ___________________________________

2. _________________________________________________________ Since when?: ___________________________________

3. _________________________________________________________ Since when?: ___________________________________

MEDICAL STATUS

Primary Health Care Practitioner: ____________________________________________ Phone: ____________________

Address: ______________________________________________________ Fax: _______________________

Other Physicians Currently Seeing: ________________________________________________________________________

General Health: Excellent Good Fair Poor Height: _________ Weight: _________

Allergies: _______________________________________________________________ Blood Type: _______________

Current Diagnosis or Medical Conditions: _________________________________________________________________________

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Current Medications: _________________________________________________________________________

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Current Vitamins or OTC Products (please list ALL; you may bring in products at time of evaluation): ______________________

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Current Herbs/etc.: __________________________________________________________________________________________

Are you currently on Natural Progesterone cream? Yes No If yes, brand name: ______________________________

How long have you been on Progesterone cream? ____________ How much are you using and when? ______________________

Current Hormone Replacement Therapy: Name: ______________________________ Strength: _________________________

Date started: ___________________________________________

How and when do you take current HRT?: _____________________________________

Previous Hormone Replacement Therapy: Name: ______________________________ Strength: _________________________

Reason for Change: ____________________________________________________________________________________________

Any lab results you may wish to enclose would be helpful for your evaluation.

Exam/Lab Results:

	DATE	SERUM Blood	SALIVA	RESULTS
FSH
PROGESTERONE
ESTRIOL (E3)
ESTRADIOL (E2)
ESTRONE (E1)
TESTOSTERONE:
TOTAL
FREE
DHEA SULFATE
CHOLESTEROL:
TRIGLYCERIDES
TOTAL
HDL
LDL

Bone Density: Yes No Date: _____________ Type: Back Hip T-Score: _____________

Have you ever had a mammogram?: Yes No Date: _____________ Results: _______________________

Have you ever had your Thyroid tested?: Yes No Date: _____________ TSH: _____ T4: _____ Free T3: _____ Other: ________

CURRENT AND PAST MEDICAL CONDITIONS
Please check the ones that apply to you:

	Y	N	Date of Diagnosis		Y	N	Date
Heart Disease				High Blood Pressure
Stroke				Varicose Veins
Clotting Defects				Diabetes
Kidney Trouble				Epilepsy
Fractures				Arthritis
Colitis				Gall bladder trouble
Irritable Bowel				Asthma
Ulcers				Autoimmune Disorder
Fibromyalgia				Osteoporosis
Chronic Fatigue				Cancer
Eating Disorder

HABITS

Dietary Restrictions: ________________________________________________________________________________________

Meal Choices: Breakfast: _____________________________________________________________________

Lunch: _______________________________________________________________________________________

Dinner: _______________________________________________________________________________________

Do you get routine exercise?: _________ What type?: ___________________________ How often?: ___________________

Do you use tobacco products?: Yes No How Much?: ________________ How Long?: _________________

Do you use alcohol products?: Yes No How Much?: ________________ How Long?: _________________

Do you use caffeine products?: Yes No How Much?: ________________ How Long?: _________________

FAMILY HISTORY

RELATIVE	IMPORTANT DISEASES	LIVING	DECEASED
Mother
Father
Brothers
Sisters
Aunts
Uncles
Paternal Grandma
Paternal Grandpa
Maternal Grandma
Maternal Grandpa

GYNECOLOGICAL HISTORY

Age at first period: ______________ Date of last period: _____________

Date of last pelvic exam: ______________ and Pap smear: _____________ Results: ________________

Have you ever had an abnormal Pap?: Yes No When?: ______________ How many times?: ______________

Treatment: _______________________________________________________________________________

Are you sexually active?: Yes No Are you trying to get pregnant?: Yes No

Current birth control method: _____________________________________________________ How long?: ___________________

Problem with it: ___________________________________________________________ How long?: ___________________

Past birth control and related problems: ________________________________________________________________________

Have you ever been on birth control?: Yes No Brand: __________________________ How long on?: ______________

Side effects: ___________________________________________________________________________________________

PLEASE FILL OUT NEXT SECTION EVEN IF NOT CYCLING NOW

How many days from start of one period to the start of next: _________________________________________________________

Number of days of flow: __________ Amount of bleeding: ______________________________________________

Amount of cramping: ___________________________________________________________________________________________

Premenstrual symptoms: ________________________________________________________________________________________

Starting and ending when?: _________________________________________________________________________________

Any current changes in your normal cycle?: __________________________________________________________________________

PLEASE FILL OUT THIS SECTION EVEN IF NOT CYCLING NOW

Any bleeding between periods?: _________________________________________________________________ When?: ______________

Any pelvic pain, pressure or fullness?: _________________ Describe: ______________________________________________________

Any unusual vaginal discharge or itching?: ______________ Describe: ______________________________________________________

Treatment: ________________________________________________________________________________________

Age at first pregnancy: ________ How many full term pregnancies?: ______________________

Problems: __________________________________________________________________________________________________

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Any interrupted pregnancies? Miscarriages?: Yes No Abortions?: Yes No

Which pregnancy?: _____________________________ How far along?: _________________________________

Have you had a tubal ligation?: Yes No When?: __________________ Cycle or symptoms change after?: _______________

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Have you had a hysterectomy?: Yes No When?: _____________________ Why?: ___________________________

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Symptoms change after hysterectomy?: ___________________________________________________________________________________________________

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Have you had any part or whole ovary removed?: Yes No When?: _________________ Why?: ______________________

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Symptoms change after?: ______________________________________________________________________________________

Age mother in menopause?: ____________________________________________________________________________________

Symptoms List The following score sheet will help you to determine whether hormone testing is needed, and which tests to order. Each category is divided into hormone deficiency and excess, as each has a different subset of symptoms. Score the symptoms which apply to you as 0 (none), 1 (mild), 2 (moderate), or 3 (severe). A score of 10 or higher in any one category (deficiency and excess combined) is probably worthwhile to test.

Estrogens (Estradiol) Estrogen Deficiency ______ Hot flashes ______ Night sweats ______ Vaginal dryness ______ Foggy thinking ______ Memory lapses ______ Incontinence ______ Tearful ______ Depressed ______ Sleep disturbances ______ Heart palpitation ______ Bone loss Estrogen Excess ______ Mood Swings (PMS) ______ Tender breasts ______ Water retention ______ Nervous ______ Irritable ______ Anxious ______ Fibrocystic breasts ______ Uterine fibroids ______ Weight gain in hips ______ Bleeding changes ______ Headaches

Progesterone Progesterone Deficiency ______ Hot flashes ______ Night sweats ______ Vaginal dryness ______ Foggy thinking ______ Memory lapses ______ Incontinence ______ Tearful ______ Depressed ______ Sleep disturbances ______ Heart palpitation ______ Bone loss Progesterone Excess ______ Sleepiness ______ Breast swelling/tenderness ______ Decreased libido ______ Mild depression ______ Candida infections

Androgens (DHEA and Testosterone) Androgen Deficiency ______ Low libido ______ Vaginal dryness ______ Foggy thinking ______ Fatigue ______ Aches/pains ______ Memory lapses ______ Incontinence ______ Depressed ______ Sleep disturbances ______ Bone loss ______ Decreased muscle mass ______ Thinning skin Androgen Excess ______ Excessive facial/body hair ______ Loss of scalp hair ______ Increased acne ______ Oily skin

Cortisol Cortisol Deficiency ______ Fatigue ______ Sugar craving ______ Allergies ______ Chemical sensitivity ______ Stress ______ Cold body temperature ______ Heart palpitations ______ Aches/pains ______ Arthritis Cortisol Excess ______ Sleep disturbances ______ Bone loss ______ Fatigue ______ Weight gain in waist ______ Loss of muscle mass ______ Thinning skin

SYMPTOMS PART I

Rate your current status for each symptom by checking the appropriate column.

Symptom	Absent	Mild	Moderate	Severe
Vaginal Dryness
Shortness of Breath
Dry Hair/Skin
Hair Loss
Short Term Memory Loss
Frequent UTIs
Heart Palpitations
Frequent Yeast Infections
Painful Intercourse
Inability to Reach Orgasm
Tearful
Food Cravings
Irritability/Moodiness
Cramps
Hot Flashes
Night Sweats
Weight Gain
Bloating
Memory Lapses
Allergies
Chemical Sensitivity
Stress
Aches & Pains
Arthritis
Loss of Muscle Mass
Thinning Skin
Recurrent Sinus Infections
Asthma/Bronchitis
Incontinence
Excessive Facial/Body Hair
Loss of Scalp Hair
Increased Acne
Oily Skin

SYMPTOMS PART II

Rate your current status for each symptom by checking the appropriate column.

Symptom	Absent	Mild	Moderate	Severe
Fluid Retention (Edema)
Afternoon Fatigue
Breast Swelling
Breast Tenderness (Frontal)
Fibrocystic Breast(s)
Uterine Fibroids
Mood Swings
Heavy/Irregular Menses
Loss of Sex Drive
Headaches (Cyclical)
Weight Gain in Hips/Thighs
Anxious/Nervous
Sensitive
Sweet Cravings
Salt Cravings
Constipation
Cold Hands & Feet
Low Body Temperature
Dry Skin & Hair
"Fuzzy" Thinking
Fatigue Upon Arising
Infertility
Fibromyalgia

Please provide a brief description of your medical history in your own words: _____________________________________

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