Hormone Replacement Therapy Intake Form

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.