Download Waiver

Bioidentical Hormone Replacement Therapy Pre-Visit Questionnaire – Women
PLEASE PRINT ALL INFORMATION CLEARLY
Patient Name:____________________________ DOB:_______________________________
Waiver
I hereby release Ervin Clinic and all of its employees and contractors including physicians from any and all liability
whatsoever associated or connected with my wellness program consultation and/or use of hormones replacement. I
hereby state that I am an adult and that I am aware there could be potential side effects associated with hormone
replacement. I hereby agree to answer truthfully all of the medical questions on my questionnaire.
I understand that no doctor, nurse, pharmacy, or administrative personnel can guarantee that hormone replacement,
even if prescribed, will provide the results I seek. Further, I may suffer adverse effect from hormone replacement. I
hereby release Ervin Clinic and all of it employees and contractors including nurse practitioner from any and all
liability whatsoever associated with any adverse effects I may suffer from my use of hormone replacement.
I am participating in this program at my own choice, at my expense and my own liability and assume all responsibility
for my use of hormone replacement I fully understand that it is my responsibility to have an annual physical
examination, including an suggested laboratory test to ensure that I have no disease(s) which might make hormone
replacement inappropriate for my condition.
Signed:__________________________________________________________________ Date:_________________
How did you hear about hormone replacement therapy? __________________________________________________
What are your goals for hormone replacement therapy?___________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Current Physicians(s):_____________________________________________________________________________
Are any of your physicians prescribing HRT? Y/N If “Yes” please provide physician names:
_______________________________________________________________________________________________
Are you concerned with your weight? Y/N
If “Yes” explain:__________________________________________
Have you ever had a bone density scan? Y/N
If “Yes” Date _____________
Have you ever had your cholesterol checked? Y/N If “Yes” Date: _____________
Results: Total _____________ HDL _____________ LDL ____________ Triglycerides_______________
Have you ever had your thyroid tested? Y/N
If “Yes”, Date:___________
Results: TSH ________ Total T4 _________ Total T3 _________ Free T3_________
Do you have regular mammograms? Y/N
If “Yes”, Date ____________ Results ________________________
Have you ever had an abnormal mammogram? Y/N
Have you ever had a breast biopsy? Y/N
Do you have regular Pap smears Y/N If Y, Date of Last _________ Results __________
Have you ever had an abnormal Pap smear? Y/N
Have you had lab work of hormones? Y/N
If “Yes”, was it within the last year? Y/N
Age at first period: ____________ Are you still menstruating? Y/N If “Yes”, date of last period? _____________
Have you ever experienced a change in frequency or intensity of your period? Y/N
Have you ever had what you would consider to be abnormal cycles? Y/N
If yes, please explain your symptoms and at what age(s) this occurred:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How many times have you been pregnant? __________ How many children have you delivered? ______________
Your age at you first live birth: ___________________
Have you had a hysterectomy? _____ No _____ Yes (date of surgery) ___________
Ovaries removed? _____ No _____ Yes
Have you had a tubal ligation? _____ No _____ Yes
Have you ever used oral contraceptives? ____ Yes _____ No
If yes, any problems using oral contraceptives? ____ Yes _____ No
Please describe: ___________________________________________________________________
Medical Conditions / Diseases: Please check all that apply to you.
_____ Heart disease (e.g. congestive heart failure)
_____ Blood clotting problems
_____ High cholesterol or lipids (e.g. hyperlipidemia)
_____ Diabetes
_____ High blood pressure (e.g. hypertension)
_____ Arthritis or joint problems
_____ Cancer
_____ Depression
_____ Ulcers (e.g. stomach, esophagus)
_____ Epilepsy
_____ Thyroid disease
_____ Headaches/migraines
_____ Hormonal related issues
_____ Eye disease (e.g. glaucoma, etc.)
_____ Lung conditions (e.g. asthma, emphysema, COPD )
_____ Other: ____________________________
Surgeries: Please include year:
Family history of Diabetes?______________________ Heart Disease?_________________ Other Cancers not
addressed?_____________
Please indicate your symptoms for the following conditions:
Fibrocystic Breast
Weight Gain
Heavy/Irregular menses
Hot Flashes
Dry Skin / Hair
Anxiety
Depression
Night Sweats
Vaginal Dryness
Headaches
Irritability
ABSENT
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MILD
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MODERATE SEVERE
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Mood Swings
Breast Tenderness
Sleep Disturbances
Cramps
Fluid Retention
Breakthrough Bleeding
Fatigue
Memory Loss
Incontinence/frequent urination
Arthritis
Difficulty reaching orgasm
Decreased libido
Hair Loss
Heart palpitations
Frequent yeast infections
Hair loss (scalp,body,pubic)
Constipation
ABSENT
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MILD
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MODERATE SEVERE
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Nutritional / Natural Supplements: Please check the products you are using:
_____ vitamins (multiple or single vitamins, i.e. B complex, E, C. carotene)
_____ minerals (calcium, magnesium, chromium, colloidal minerals, single minerals)
_____ herbs (Ginseng, Ginkgo Biloba, Echinacea, herbal medicinal teas, tinctures, etc.)
_____ enzymes (digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)
_____ nutrition / protein supplements ( shark cartilage, protein powders, amino acids, fish oils)
_____ others (glucosamine, etc.): ___________________________________________________________
Do you use tobacco?
Do you use alcohol?
Do you use caffeine?
How often and how much?
_____ Yes _____ No __________________________________
_____ Yes _____ No __________________________________
_____ Yes _____ No __________________________________
Legal Name: _____________________________________________________
Address: ________________________________________________________
City ______________________ State ______ Zip __________
#1 Phone ____________________________ Home Work Cell Other
#2 Phone ____________________________ Home Work Cell Other
#3 Phone ____________________________ Home Work Cell Other
Email Address _____________________________________________
Employer ______________________________________
Insurance Company _____________________ ID# ___________________ Group # ____________
Are you the primary insured Y N If No, who is? ____________________________
Relationship to you ____________ Their Birth Date ___________ Employer __________________