HRT Patient Intake Form Template
Hormone replacement therapy requires thorough patient evaluation before treatment initiation. This intake form template covers the clinical information needed for prescribing estrogen, progesterone, testosterone, and bioidentical hormone therapy (BHRT) for menopausal and perimenopausal patients. Designed for women's health practices, integrative medicine clinics, and primary care providers offering HRT, this form includes validated symptom assessment, breast cancer risk screening, cardiovascular evaluation, and BHRT-specific disclosures. The template follows North American Menopause Society (NAMS) position statements and Endocrine Society guidelines.
Form Preview
Section 1 of 6
Patient Demographics
Please provide your contact information.
Full Name *
Jane Smith
Date of Birth *
...
Phone *
(555) 000-0000
Email *
Address *
123 Main St, City, ST 00000
Primary Care Physician
...
OB/GYN
...
Section 2 of 6
Menstrual & Reproductive History
Tell us about your menstrual and reproductive history.
Menopausal Status *
Premenopausal (regular periods)
Age at Last Menstrual Period
e.g., 49
Number of Pregnancies
e.g., 2
History of hysterectomy or oophorectomy?
Current or recent hormone use?
If yes, describe current/recent hormone therapy
Medication, dose, duration, prescriber
Section 3 of 6
Symptom Assessment
Check any symptoms you've been experiencing.
Current Symptoms (check all that apply)
Symptom Severity *
Mild
How long have you experienced these symptoms? *
Less than 6 months
Section 4 of 6
Medical History & Risk Screening
Please check any conditions you have or have had.
Medical History
Date of last mammogram
...
Date of last Pap smear
...
Date of last DEXA / bone density scan
...
Smoking / Tobacco Status *
Never
Alcohol Use *
None
Section 5 of 6
Current Medications & Supplements
Please list everything you're currently taking.
Current Medications *
List all medications with dosages
Current Supplements
Vitamins, herbal, OTC
Allergies *
Medications, foods, latex
Section 6 of 6
Treatment Preferences
Let us know your preferences so we can recommend the right approach.
Preferred Hormone Type *
No preference - provider recommendation
Preferred Delivery Method
No preference
How did you hear about our practice?
Online search
This is a preview. Actual form will be customized with your practice branding.
Compliance & Regulatory Notes
NAMS recommends individualized HRT assessment based on symptom severity, time since menopause, cardiovascular risk, and breast cancer risk. HRT is generally not recommended for women more than 10 years past menopause or over age 60 without prior hormone use. See NAMS: https://www.menopause.org/for-science/nams-position-statements
Breast cancer screening (mammogram) should be current before initiating estrogen-containing HRT. The WHI study demonstrated increased breast cancer risk with combined estrogen-progestin therapy after long-term use.
For practices offering bioidentical hormone therapy (BHRT) through compounding pharmacies, additional consent disclosures are recommended. The FDA and Endocrine Society have stated that 'bioidentical' compounded hormones are not proven safer or more effective than FDA-approved alternatives. See FDA: https://www.fda.gov/consumers/consumer-updates/bio-identicals-sorting-myths-facts
Estrogen therapy in patients with an intact uterus requires concurrent progesterone to prevent endometrial hyperplasia. This is a clinical standard of care.
HRT patient data is PHI under HIPAA. Ensure secure collection and storage. See HHS: https://www.hhs.gov/hipaa/index.html
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Frequently Asked Questions
What is the difference between HRT and BHRT?
HRT (hormone replacement therapy) is a general term covering all hormone treatments. BHRT (bioidentical hormone replacement therapy) specifically uses hormones chemically identical to those the body produces, often compounded by a pharmacy. Both FDA-approved and compounded options exist for bioidentical hormones.
What lab work should be ordered before starting HRT?
Common baseline labs include estradiol, FSH, progesterone, total and free testosterone, DHEA-S, thyroid panel, CBC, comprehensive metabolic panel, and lipid panel. Mammogram and Pap smear should be current.
Can men use this intake form for hormone therapy?
This form is designed for female HRT. For male patients seeking testosterone replacement, use the TRT Patient Intake Form, which covers male-specific symptoms, PSA screening, and fertility considerations.
Is HRT safe for women with a family history of breast cancer?
This requires individualized clinical evaluation. NAMS guidelines do not automatically contraindicate HRT for women with a family history, but a thorough risk assessment (including genetic testing considerations) is essential. Document the risk-benefit discussion in the medical record.