Hormone Replacement Therapy Intake Form
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Hormone Replacement Therapy Intake Form
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The Hormone Replacement Therapy Intake Form is built for HRT clinics, anti-aging and longevity practices, endocrinology offices, men's health clinics, and women's hormone health centers that prescribe testosterone therapy, estrogen replacement, progesterone, DHEA, thyroid hormones, or bioidentical hormone pellets. This HRT patient intake form collects a thorough symptom assessment using validated scales for fatigue, mood changes, libido, hot flashes, night sweats, brain fog, muscle loss, weight gain, hair thinning, and sleep disruption, allowing the practitioner to quantify symptom severity at baseline and track improvement over the course of treatment.
The form captures a detailed hormone treatment history including any prior HRT regimens (type, route of administration, dosage, duration, and reason for discontinuation), surgical history relevant to hormonal status (hysterectomy, oophorectomy, orchiectomy, thyroidectomy), and reproductive history. A comprehensive medical conditions checklist screens for cardiovascular risk factors, blood clotting disorders, hormone-sensitive cancers, liver disease, and other contraindications to hormone therapy. The medications list section documents current prescriptions, over-the-counter drugs, and supplements so the prescribing provider can evaluate drug interactions. Patients upload recent lab results (CBC, comprehensive metabolic panel, lipid panel, thyroid panel, testosterone total and free, estradiol, progesterone, DHEA-S, IGF-1, PSA, hemoglobin A1c) directly through the form, saving the clinic the effort of chasing records.
A treatment goals section lets patients describe their desired outcomes in their own words, while the consent agreement covers the risks and benefits of hormone replacement therapy, the requirement for ongoing lab monitoring, the potential for side effects such as erythrocytosis, mood changes, acne, and fluid retention, and the patient's commitment to follow-up appointments. This testosterone therapy intake and HRT patient intake form ensures clinics have all the clinical data they need before the first consultation, reducing visit times and enabling a focused, productive initial appointment.
What's included
- Validated symptom severity assessment for common hormone imbalance indicators
- Prior hormone treatment history with regimen details and discontinuation reasons
- Medical conditions screening for HRT contraindications
- Current medications, supplements, and allergy documentation
- Lab results upload for pre-consultation review
- Treatment goals in patient's own words
- Informed consent covering HRT risks, benefits, and monitoring requirements
- Consent agreement with e-signature
- Structured medication list with dosage and frequency tracking
- Medical conditions checklist
- Appointment booking with provider selection
Who uses this template
- HRT and bioidentical hormone clinics onboarding new patients with symptom baselines
- Men's health and testosterone replacement therapy practices collecting intake data
- Women's hormone health centers documenting menopausal and perimenopausal symptom profiles
- Anti-aging and longevity practices capturing comprehensive endocrine health assessments
All form fields
14 fields across 3 pages. Customize any field after signing up.
How to use the Hormone Replacement Therapy Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Hormone Replacement Therapy Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Hormone Replacement Therapy Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Hormone Replacement Therapy Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Hormone Replacement Therapy Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Hormone Replacement Therapy Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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