15714 Huebner, Bldg. 5 San Antonio, TX Huebner Office Plaza

La Femme OBGYN

Virginia Aguilar, D.O., F.A.C.O.G.

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Women HRT Questionnaire

New Patient Hormone Replacement Therapy Questionnaire (Women)

Contact Us

Patient Information:

Patient Information:

Full Name:

Date of Birth:

Phone Number:

Email:

Preferred method of contact:

Phone Call

Text Message

Email

1. Medical History

1. Medical History

Do you have any pre-existing medical conditions? (e.g., diabetes, thyroid disorders, heart disease)

Yes

No

Please specify:

Are you currently taking any medications or supplements?

Yes

No

Please specify:

Do you have any known allergies?

Yes

No

Please specify:

Have you had any surgeries, including hysterectomy or oophorectomy (removal of ovaries)?

Yes

No

Please specify:

Do you have a history of breast cancer, ovarian cancer, or other hormone-related conditions?

Yes

No

Please specify:

2. Hormonal Symptoms

2. Hormonal Symptoms

Which of the following symptoms are you currently experiencing? (Check all that apply)

Hot Flashes or Night Sweats

Mood Swings or Irritability

Fatigue or Low Energy

Weight Gain (especially around the abdomen)

Decreased Libido (Sex Drive)

Vaginal Dryness or Discomfort

Trouble Sleeping (Insomnia)

Brain Fog or Difficulty Concentrating

Thinning Hair or Hair Loss

Irregular or Heavy Periods (if applicable)

Anxiety or Depression

Other (Please specify):

How long have you been experiencing these symptoms?

Less than 6 months

6-12 months

Over a year

3. Menstrual and Reproductive Health

3. Menstrual and Reproductive Health

Are you currently experiencing menopause or perimenopause?

Yes

No

When was your last menstrual period?

Less than 6 months ago

6-12 months ago

Over a year ago

Have you had difficulty with fertility in the past?

Yes

No

Have you ever been pregnant?

Yes

No

4. Lifestyle and Habits

4. Lifestyle and Habits

How would you describe your typical diet?

Balanced and Healthy

Moderately Healthy

Unhealthy

Do you exercise regularly?

Yes

No

Type and frequency:

Do you smoke or use tobacco products?

Yes

No

Do you consume alcohol?

Yes

No

Frequency:

How many hours of sleep do you get on average per night?

How would you rate your stress level?

Low

Moderate

High

5. Hormone Replacement Therapy (HRT) Interest

5. Hormone Replacement Therapy (HRT) Interest

Have you undergone Hormone Replacement Therapy in the past?

Yes

No

Please specify when and where:

What do you hope to achieve from HRT? (Check all that apply)

Relief from Hot Flashes and Night Sweats

Increased Energy

Improved Libido

Better Mood and Mental Clarity

Improved Sleep

Relief from Vaginal Dryness

Other (Please specify):

Do you have any concerns or questions about HRT?

6. Family Medical History

6. Family Medical History

Does anyone in your family have a history of hormone-related conditions or early menopause?

Yes

No

Please specify:

Do you have a family history of breast cancer, ovarian cancer, or heart disease?

Ye

No

Please specify:

7. Additional Information

7. Additional Information

Is there anything else you would like us to know about your health or symptoms?

What are your expectations from Hormone Replacement Therapy?

8. Consent and Agreement

8. Consent and Agreement

Are you willing to undergo blood tests to evaluate your hormone levels?

Yes

No

Do you consent to discussing your health and hormone therapy options with our medical team?

Ye

No

Thank you for contacting us.
We will get back to you as soon as possible.

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La Femme OBGYN

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Home
Meet the Team
Gynecology Services
Pre-Natal Care
Weight Loss Injections
Hormone Replacement Therapy
Financing
Contact Us

CONTACT INFORMATION

Phone: (210) 492-2300

Se Habla Espanol

Email: vaguilar011305@gmail.com

Address: 15714 Huebner, Bldg. 5 San Antonio, TX Huebner Office Plaza

BUSINESS HOURS

Mon, Tue, Thu: 9:00 am - 5:00 pm
Wednesday: 8:00 am - 5:00 pm
Friday: 8:00 am - 12:00 pm
Sat - Sun: Closed

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