Moses Lake Professional Pharmacy

BHRT Consultation Form For Men

Bio-Identical Hormone Replacement Therapy (BHRT) Consultation Form for Men

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*Indicates required field.
*Date:

Name: Age: Birthdate:

City State/Province *Zip/Postal code:

Email: Home Phone:

Work Phone: FAX: Occupation:



What is your greatest need or problem? (List the most important; then list other issues in order of importance):


Who is your current doctor and have you discussed this with them?:


Your current medical conditions or diagnoses:

Drug allergies:

Allergies to food, pollens, environment, etc:

Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:

Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:

Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:

If you are you currently taking medication for a thyroid condition, which one and dose?


Do you use tobacco products? Yes No
What? How Much? For How Long?

Do you use alcohol products? Yes No
What? How Much? For How Long?

Do you use caffeine products? Yes No What? How Much?

Do you use recreational drugs? Yes No What? How Much?

How much water do you drink in one day (24 hr)?	oz. glasses.

Is your drinking water from a:
home well city water distilled water bottled water water purifier

Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):

When was your last: General medical exam:


CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks. 0 = None (symptom not present) 1 = Mild (present but not distressing) 2 = Moderate (distressing, but not interfering with daily life) 3 = Severe (very distressing, interferes with daily life) If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.

Burned Out Feeling	0 1 2 3

Decreased Mental Sharpness	0 1 2 3

Nervous	0 1 2 3

Decreased Stamina	0 1 2 3

Decreased Flexibility	0 1 2 3

Elevated Triglycerides	0 1 2 3

Headaches	0 1 2 3

Sensitivity to Chemicals	0 1 2 3

Decreased Urine Flow	0 1 2 3

Bone Loss	0 1 2 3

Swelling or Puffy Eyes/Face	0 1 2 3

Nails Breaking or Brittle	0 1 2 3

Rapid Heartbeat	0 1 2 3

Low Blood Sugar	0 1 2 3



Oily Skin or Hair	0 1 2 3

Apathy	0 1 2 3

Depressed	0 1 2 3

Anxious	0 1 2 3

Decreased Muscle Size	0 1 2 3

Neck or Back Pain	0 1 2 3

Sugar Cravings	0 1 2 3

Ringing in Ears	0 1 2 3

Decreased Erections	0 1 2 3



Increased Urinary Urge	0 1 2 3

Stress	0 1 2 3

Slow Pulse Rate	0 1 2 3

Thinning Skin	0 1 2 3

Hearing Loss	0 1 2 3

High Blood Pressure	0 1 2 3

Acne	0 1 2 3

Difficulty Sleeping	0 1 2 3

Mental Fatigue	0 1 2 3

Morning Fatigue	0 1 2 3

Sore Muscles	0 1 2 3

Weight Gain - Breast or Hips	0 1 2 3

Heart Palpitations	0 1 2 3

Cold Body Temperature	0 1 2 3

Decreased Libido	0 1 2 3



Hot Flashes	0 1 2 3

Rapid Aging	0 1 2 3

Decreased Sweating	0 1 2 3

Infertility Problems	0 1 2 3

Goiter	0 1 2 3

Low Blood Pressure	0 1 2 3

Aggressive Behavior	0 1 2 3

Increased Forgetfulness	0 1 2 3

Irritable	0 1 2 3

Evening Fatigue	0 1 2 3

Increased Joint Pain	0 1 2 3

Weight Gain - Waist	0 1 2 3

Dizzy Spells	0 1 2 3

Allergies	0 1 2 3

Prostate Problems	0 1 2 3

Night Sweats	0 1 2 3

High Cholesterol	0 1 2 3

Hair Dry or Brittle	0 1 2 3

Constipated	0 1 2 3

Hoarseness	0 1 2 3

Numbness - Feet or Hands	0 1 2 3

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