3 Hormone Replacement Therapy Questionnaire Personal Data ... 2025

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The document is a comprehensive Hormone Replacement Therapy Questionnaire that collects personal, medical, and family history from patients seeking hormone therapy. It includes sections on personal data, medical history, symptoms experienced with aging, hormone therapy history, and informed consent for treatment. The document outlines the responsibilities of both the patient and physician regarding payment for services, potential risks associated with hormone therapy, and the understanding that insurance may not cover these treatments. It emphasizes the importance of patient compliance and provides details on various hormones that may be prescribed.

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Click ‘Get Form’ to open the 3 Hormone Replacement Therapy Questionnaire in the editor.
Begin by filling out the 'Personal Data' section. Enter your name, date of birth, gender, and age. Make sure to provide your primary physician’s name and office number for reference.
Move on to 'Personal Medical History'. Carefully check any relevant medical conditions you have experienced and answer questions regarding smoking and alcohol consumption.
For women, complete the specific questions about menstruation and pregnancy status. If applicable, provide details about recent mammograms or Pap smears.
In the 'Family Medical History' section, list any relevant health issues that family members have faced, specifying their relationship to you.
Finally, review all sections for accuracy before signing at the bottom of the form. Ensure that all required fields are completed.

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What are some important considerations for complications of hormonal replacement?

The principal risks of HRT are thromboembolic disease (venous thromboembolism (VTE) and pulmonary embolism), stroke, breast and endometrial cancer, and gallbladder disease. Large studies, including the WHI and the Million Women Study (MWS), raised concerns and controversy over the use of HRT [18, 26].

What is the current recommendation for hormone replacement therapy?

Standard recommendations \u2014 The standard recommendation for duration of menopausal hormone therapy (MHT) use has been five years or less (and not beyond age 60 years) [66]. However, for most women, hot flashes persist for as long as 10 to 20 years after the final menstrual period.

At what age should a woman stop taking hormone replacement?

If you are healthy, most experts agree that HRT is safe to use at the lowest dose that helps for the shortest time needed. If you're 59 or older, or have been on hormones for 5 years, you should talk to your doctor about quitting.

What are the risks of hormonal therapy?

Stroke, blood clots, and heart attack. Women who took either combined hormone therapy or estrogen alone had an increased risk of stroke, blood clots, and heart attack (1, 2). For women in both groups, however, this risk returned to normal levels after they stopped taking the medication (3, 4).

What is the latest research on HRT?

New research suggests that HRT is generally linked to only small increased risks. Different types of HRT were linked to different risks of breast cancer. The details of this study should help guide discussions between doctors and women considering HRT. Symptoms of the menopause can be severe in many women.

What questions should I ask about hormone therapy?

Questions \u201cAre hormones right for me? Why? What are the benefits? What are the serious risks and common side effects? How long should I use hormone therapy? What is the lowest dose that will work for me? Are there any non-hormone medicines that I can take?\u201d

How do I choose the best HRT?

There are two ways of taking it: cyclical combined HRT is best if you have menopausal symptoms and still have periods. This involves having a gap between taking progestogen for a period of time. Continuous combined HRT is recommended if you are post-menopausal and have not had a period for a year.

Which is a serious potential side effect related to estrogen therapy?

Hormone replacement therapy may increase the risk of heart attack, stroke, breast cancer, and blood clots in the lungs and legs.