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The Medicine Shoppe 1405 NE Douglas Lee's Summit, MO 64086 Phone: 816-524-8444 Fax: 816-246-5493
BHRT Female Symptom Update
Date
Name______________________________________________
Date of Birth
Address Home Phone (
)
Cell Phone (
)
Have there been any changes in any of your medications in the past year? If so, please list:
Currently having periods? Yes OR No
If so, when was your last period?__________________
Please check all symptoms below that apply (this is very important to the evaluation process) Symptoms of low Progesterone? __ Swollen Breasts __ Headaches __ Anxiety/Irritability ___per week __ Irregular menses __ Cramping __ Infertility __ Acne __ Weight Gain __ Low Sex Drive __ Mood Swings __ Depression __ PMS __ Fuzzy Thinking __ Joint Pain __ Low Energy __ Food Cravings Symptoms of low Testosterone? __ Depression __ Urine Leakage __ Joint Pain __ Low Sex Drive __ Heart Palpitations __ Memory Lapses __ Fibromyalgia __ Vaginal Dryness
Symptoms of low Estrogen? __ Hot Flashes __ Insomnia __ Dry Skin ___per week __ Foggy Thinking __ Heart Palpitations __ Painful Intercourse __ Low Sex Drive __ Night Sweats __ Vaginal Dryness/Atrophy ___per week __ Memory Lapses __ Yeast Infections __ Depression __ Bone Loss __ Headaches ___per week __ Low Energy __ Bone Loss __ Muscle Weakness __ Thinning Skin
Have any symptoms become more frequent/bothersome in the past few months?
Signing here gives the pharmacist permission to make dosing change suggestions to your physician. X ___________________________________________________Date: ___________________