Hormone Replacement Medical History Form

Please correct the errors described below.

Your answers on this form will help us understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Best estimates are fine, if you cannot remember specific details

Medications:

Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs

Add Another Medication

Allergies or Reactions to Medications and Foods:

Add Another Allergy or Reaction

Health Maintenance:

When were your most recent Screening tests:

Immunizations

Personal Medical History

Please indicate whether you have had any of the following medical problems (with dates)

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Surgical History

Family History:

Mother

Maternal grandmother

Maternal grandfather

Father

Paternal grandmother

Paternal grandfather

Social History

TOBACCO USE

ALCOHOL USE

DRUG USE

SEXUAL ACTIVITY

CAFFEINE INTAKE

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WEIGHT

DIET

EXERCISE

Socioeconomics

Specialty History:

For women:

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