Female Hormone Evaluation Questionnaire
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4CONFIDENTIAL FEMALE HORMONE EVALUATION
Today’s Date: ___________________
Name: _______________________________________
Birthdate: ________________
Age: _______
Address: __________________________________________________________________________________
Street
City
State
Zip
Phone: ________________________________
Email: __________________________________________
Height: __________ Weight: _________
Desired Weight: __________
How Often and how much?
Do you use tobacco?
Yes
No
_________________________________________
Do you use alcohol?
Yes
No
_________________________________________
Do you use caffeine?
Yes
No
_________________________________________
Do you exercise?
Yes
No
_________________________________________
Allergies: Please list any allergies and describe the reaction that occurred
Drugs: ____________________________________________________________________________________
Foods: ____________________________________________________________________________________
Other: ____________________________________________________________________________________
Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include
vitamins, herbals, and supplements): ___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer
from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Current Prescription Medications (including hormones):
Medication Name and Strength
Date Started
How Often per day
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Parent category: Medical