Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Hormone Replacement Therapy Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Email Address
Phone Number
Symptom Severity Assessment
Hormone Treatment History
Medical Conditions Screening
Additional details
Current Medications & Supplements
| Medication | Dose | How often |
|---|---|---|
Known Allergies
| Allergy | Reaction |
|---|---|
Please bring to your visit: recent lab results
Surgical & Reproductive History
Treatment Goals
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Hormone Replacement Therapy Intake Form template from formisoft.com. formisoft.com/intake-templates/hormone-therapy-intake