BHRT Analysis Form Female

First and Last Name (*)	Invalid Input
Birthdate (*)	Invalid Input
Age (*)	Invalid Input
Date (*)	Invalid Input
Address (*)	Invalid Input
City, State, Zip Code (*)	Invalid Input
E-mail Address (*)	Invalid Input
Home Phone (*)	Invalid Input
Work Phone	Invalid Input
Fax	Invalid Input
Occupation	Invalid Input
What is your greatest need or problem? (list the most important; then list other issues in order of importance)	Invalid Input
Your current medical conditions or diagnoses:	Invalid Input
Drug allergies	Invalid Input
Allergies to food, pollens, environment, etc:	Invalid Input
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:	Invalid Input
Indicate any herbal products you have taken: (Evening Primrose Oil-EPO, Chaste Tre Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc). Other:	Invalid Input
Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using	Invalid Input
If you are currently taking medication for a thyroid condition, which one and what dose	Invalid Input
Have you ever had a bone density scan?	YesNo Invalid Input
If yes, when	Invalid Input
What were the results	Invalid Input
Do you use tabacco products?	YesNo Invalid Input
What and how much	Invalid Input
Do you use alcohol products?	YesNo Invalid Input
For how long?	Invalid Input
What and how much?	Invalid Input
Do you use caffeine products?	YesNo Invalid Input
What and how much?	Invalid Input
Do you use recreational drugs?	YesNo Invalid Input
What and how much?	Invalid Input
How much water do you drink in one day (24 hours)? Oz or lasses	Invalid Input
Is your drinking water from:	Home wellCity waterDistilled waterBottled waterWater purifier Invalid Input
Dietary restrictions (such as salt, carbohyrates, milk products, red meat, etc.)	Invalid Input
When was your last general medical exam?	Invalid Input
When was your last pelvic exam?	Invalid Input
Have you ever had an abnormal Pap?	YesNo Invalid Input
When and what was the treatment?	Invalid Input
At what ages was your first period (menarche)?	Invalid Input
When was your most recent or last period (LMP)?	Invalid Input
Do you still have your period?	YesNo Invalid Input
If yes, how many days from the start of one period to the start of the next?	Invalid Input
Number of days of flow?	Invalid Input
Amount of bleeding?	Invalid Input
Describe any cramping or pain you may have?	Invalid Input
Doyou have pain at any other time in your cycle?	YesNo Invalid Input
Where, when, and how long?	Invalid Input
Any current changes in your normal cycle?	Invalid Input
Any bleeding between periods (IMB)? If so, when and describe	Invalid Input
What were your periods like as a teenager?	Invalid Input
If you have ever had Premenstrual Symptoms (PMS), please decribe	Invalid Input
How long have you had PMS symptoms?	Invalid Input
Starting and ending when?	Invalid Input
If your periods have ever been difficult, irregular, or agnormal in any way, please describe	Invalid Input
If you ar ecurrently having any pelvic pain, pressure, or fullness, please describe	Invalid Input
Describe any recent unusual vaginal discharge or itching	Invalid Input
Have you had tubal ligation (tubes tied)?	YesNo Invalid Input
If yes, when and at what age?	Invalid Input
Have you had a hysterectomy (Uterus removed)?	YesNo Invalid Input
If yes, when and why	Invalid Input
Have you had a oophorectomy (Ovaries removed)?	YesNoPart Invalid Input
If yes, what part and why?	Invalid Input
Was there any problems associated with the surgery or removal of any of these organs?	Invalid Input
Have your doctor diagnosed menopause, or told you that you are in menopause?	YesNo Invalid Input
If at age 40 or earlier: Have you been diagnosed with Premature Ovarian Failure?	YesNo Invalid Input
Have you ever been pregnant?	YesNo Invalid Input
Are you trying to get pregnant?	YesNo Invalid Input
What was your age during your first pregnancy?	Invalid Input
Did you have any problems?	YesNo Invalid Input
How many times have you been pregnant (gravida)?	Invalid Input
How many pregnancies resulted in the birth of living children (para)?	Invalid Input
Were there any problems?	YesNo Invalid Input
Any interrupted pregnancies (miscarriages or abortions)?	Invalid Input
Current birth control method?	Invalid Input
Treatment for any of the above?	Invalid Input
How long and do you have any problems?	Invalid Input
Have you ever used any of the following birth control methods?	Oral Contraceptives (Birth Control Pill)Intra-Uterine Device (IUD) Invalid Input
FOr how long and were there any side effects or problems?	Invalid Input
When was your last mammogram? Results?	Invalid Input
Do you examine your breasts monthly?	YesNo Invalid Input
Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Provide details	Invalid Input
Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions?	YesNo Invalid Input
If yes, at what age?	Invalid Input
If your doctor has recently ordered lab tests or diagnostic procedures for you, please provide details, including whether the tests or procedure was performed and the results	Invalid Input
	When Fusion RX staff members receive and review the results of your input form, you will be contacted via email or phone. Thank you.
	CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.
	0=None (symptoms not present) 1=Mild (present but not distressing) 2=Moderate (distressing but not interfering with daily life) 3=Severe (very distressing, interferes with daily life)
	If you wish to add comments or details, please send separately via email to us, indicating your first and last name in the email. Thank you.
Hot flashes	0123 Invalid Input
Night sweats	0123 Invalid Input
Light-headed feelings/dizziness	0123 Invalid Input
Headaches	0123 Invalid Input
Sleep disorders/Sleeplessness	0123 Invalid Input
Irritability	0123 Invalid Input
Unusual tiredness/Fatgue	0123 Invalid Input
Depression	0123 Invalid Input
Anxiety/Tension/Nervousness	0123 Invalid Input
Mood swings/Mood changes	0123 Invalid Input
Confusion/Difficulty concentrating	0123 Invalid Input
Forgetfulness/Short-term memory loss	0123 Invalid Input
Angry outbursts/Arguments/Violent tendencies	0123 Invalid Input
Crying easily	0123 Invalid Input
Backache	0123 Invalid Input
Joint pains	0123 Invalid Input
Muscle pains	0123 Invalid Input
Muscle pains/spasms	0123 Invalid Input
Problems with wound healing time	0123 Invalid Input
Acne/Pimples/Skin flushing	0123 Invalid Input
New facial hair	0123 Invalid Input
Dry skin/Dry hair	0123 Invalid Input
Crawling feeling under skin	0123 Invalid Input
Urinary frequency	0123 Invalid Input
Vaginal dryness	0123 Invalid Input
Abnormal bleeding	0123 Invalid Input
Pelvic pain, pressure, fullness or bloating	0123 Invalid Input
Uncomfortable intercourse	0123 Invalid Input
Loss of sexual feeling/desire	0123 Invalid Input
Loss of arousability & capacity for orgasm	0123 Invalid Input
Loss of sexual sensitivity	0123 Invalid Input
Loss of vitality	0123 Invalid Input
Nipple sensitivity	0123 Invalid Input
Discharge or leaking from nipples	0123 Invalid Input
Breast tenderness	0123 Invalid Input
Loss of pubic hair	0123 Invalid Input
Swelling of hands, ankles or breasts	0123 Invalid Input
Heart palpitations	0123 Invalid Input
Shortness of breath	0123 Invalid Input
Food/sweets/salt cravings	0123 Invalid Input
Increased appetite/weight gain	0123 Invalid Input
Tightness in neck/shoulders	0123 Invalid Input
Visual disturbance or decreased vision	0123 Invalid Input
Difficulty hearing	0123 Invalid Input
Diminished sense of taste	0123 Invalid Input
Diminished sense of smell	0123 Invalid Input
Submit