Female HRT Screening Questionnaire

Please answer the following questions.

Email
Name
Phone Number
Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)

Hot flashes, sweating (episodes of sweating)

Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early)

Irritability (feeling nervous, inner tension, feeling aggressive)

Anxiety (inner restlessness, feeling panicky)

Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)

Sexual problems (change in sexual desire, in sexual activity and satisfaction)

Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)

Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)

Joint and muscular discomfort (pain in the joints, rheumatoid complaints)

History of breast or other gynecological cancer?

History of blood clots or stroke?

A blood clotting disorder?

History of coronary artery disease, such as a heart attack, stent, or coronary bypass?

Current smoker?

Currently being treated for cancer?

History of a brain tumor, called a meningioma?

Heavy vaginal bleeding or fibroids?

Serious liver disease (not just “fatty liver”)?

Serious kidney disease?

Uncontrolled high blood pressure?

Are you age 65 or older?