SummitRxPharmacy.com | P: 816-524-8444 | 1405 NE Douglas | Lee's Summit, MO

FEMALE HRT SYMPTOM UPDATE

First Name *

Last Name *

Date of Birth * +

Mobile Phone Number
(Home number if no mobile number) *

Street Address *

City *

State *

Zip Code *

Email Address *

Confirm Email Address *

Have there been any changes in any of your medications in the past year? If so, please list them below: *

Height *

Weight *

Please check all symptoms below that apply (this is very important to the evaluation process):

Symptoms of low Progesterone?

Symptoms of low Estrogen?

If you checked night sweats, insomnia, or headaches, please list the number of times per week below:

Symptoms of low Testosterone?

Have any symptoms become more frequent/bothersome in the past few months?

Signing here give the pharmacist permission to make dosing change suggestions to your physician. *

clear

Swollen Breasts	Anxiety/Irritability	Irregular Menses
Infertility	Weight Gain	Mood Swings
PMS	Joint Pain	Food Cravings
Cramping	Acne	Low Sex Drive
Depression	Fuzzy Thinking	Low Energy
Headaches (list number per week below) Headaches (list number per week below)

Depression	Joint Pain	Heart Palpitations
Fibromyalgia	Urine Leakage	Low Sex Drive
Memory Lapses	Vaginal Dryness	Low Energy
Bone Loss	Muscle Weakness	Thinning Skin/Scalp Hair Loss