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BHRT Analysis

This form is used in conjunction with our Salvia Hormone Testing form, found here.

General Information

Name: *
Age: *
City: *
State: *
Zip Code:
Email: *
Home Phone: *
Work Phone: *

Current Condition and Medical History

What is your Greatest Need or Problem?
Please list all issues in order of importance

Please list any current Medical Conditions or Diagnoses:

Please list any Drug Allergies:

Please list any Other Allergies:  (i.e. - food, pollens, environment, etc.)

Medication, Substance Use, and Dietary Consumption

Prescription Medications:
Please list all prescription medications taken in the last 6 months, their strength, and how you take them:

Herbal Products:
Please list any herbal products you have recently taken (i.e. - Evening Primrose Oil [EPO], Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc.)

Additional Vitamins, Supplements, or Medications:
Please list all other vitamins, supplements, non-prescription medicines, or other OTC products you are currently using

Tobacco Use:
Do you use tobacco products?   

How Much:
For How Long:

Alcohol Use:
Do you use alcohol products?   

How Much:
For How Long:

Caffeine Use:
Do you use caffeine products?   

How Much:

Recreational Drug Use:
Do you use recreational drugs?   

How Much:

Water Intake:
How much water do you drink in one day (24 hour period)?

Ounces:  - or -

Water Source:
Where does your drinking water normally come from?

Dietary Restrictions:
Please list any dietary restrictions you may have (i.e. - salt, carbohydrates, milk products, red meat, etc.)

Exams, Procedures, and Tests

Bone Density Scan:
Have you ever had a bone density scan?   


When was your last General Medical Exam: 

When was your last Pelvic Exam: 

Gynecological and Menstruation History

Have you ever had an Abnormal Pap?   


At what age was your First Period (menarche): 

When was your Most Recent or Last Period (LMP): 

Your Period:
Do you Still Have your Period?   

Days Between Each Period:
Number of Days of Flow:
Amount of Bleeding:

Describe any Cramping or Pain you may have:

Do you have Pain at any Other Time in your Cycle?   

How Long:

Are there any Current Changes in your Normal Cycle:  (if so, please describe)

Do you have any Bleeding between Periods (IMB):  (if so, please describe)

What were your Periods like as a Teenager:

Have you ever had Premenstrual Symptoms (PMS): (if so, please describe)

How long have you had PMS Symptoms? When do they generally start and end?

Have your Periods ever been Difficult, Irregular, or Abnormal in any way: (if so, please describe)

Are you currently having an Pelvic Pain, Pressure, or Fullness: (if so, please describe)

Have you had any recent unusual Vaginal Discharge or Itching: (if so, please describe)

Have you had Treatment for any of the conditions listed above: (if so, please describe)


Have you ever had your Tubes Tied (tubal ligation)?   

At What Age:

Have you ever had your Uterus Removed (hysterectomy)?   


Have you ever had your Ovaries Removed (oophorectomy)?   

How Many:

Were there any problems associated with the surgery or removal of any organs:


Has your doctor diagnosed menopause, or told you that you are in menopause?   

At What Age:

Were you ever diagnosed with Premature Ovarian Failure at or before the age of 40?   

Pregnancy and Child Birth

Have you ever been Pregnant?   

Are you trying to get Pregnant?   

What was your Age at your First Pregnancy:

How Many Times have you been Pregnant (gravida):

How Many Pregnancies resulted in the Birth of Living Children (para):

Have you had any Problems During Pregnancy: (if so, please describe)

Have you had any Interrupted Pregnancies (Miscarriages or Abortions): (if so, please describe)

Birth Control and Contraceptives

Are you Currently Using Birth Control?   

How Long:
Any Problems:

Have you ever used Oral Contraceptives (Birth Control Pills)?   

How Long:
Any Side Effects:

Have you ever used an Intra-Uterine Device (IUD)?   

Any Problems:

Breast Exams and Health

When was your last Mammogram: 

What were the Results of that Mammogram: 

Do you Examine your Breasts Monthly?   

Have you ever experienced Breast Pain, Discomfort, Nipple Discharge, or Swelling other than when Pregnant: (if so, please describe)

Have you ever been Diagnosed with Lumps, Fibroids, Breast Cancer, or Similar Breast Conditions: (if so, please describe)

If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:


Check the appropriate box for each symptom that best describes how you have been feeling for the past 3 weeks.

None:  symptom not present
Mild:  present but not distressing
Moderate:  distressing, but not interfering with daily life
Severe:  very distressing, interferes with daily life

Hot flushes
Night sweats
Light-headed feelings/dizziness
Sleep disorders/Sleeplessness
Unusual tiredness/Fatigue
Mood swings/Mood changes
Confusion/Difficulty concentrating
Forgetfulness/Short-term memory loss
Angry outbursts/Arguments/ Violent tendencies
Crying easily
Joint pains
Muscle pains
Muscle cramps/spasms
Problems with wound healing time
Acne/Pimples/Skin flushing
New facial hair
Dry skin/Dry hair
Crawling feeling under skin
Frequent Urinary Tract Infection (UTI)
Urinary frequency
Vaginal dryness
Abnormal bleeding
Pelvic pain, pressure, fullness, or bloating
Uncomfortable intercourse
Loss of sexual feeling/desire
Loss of arousability & capacity for orgasm
Loss of sexual sensitivity
Loss of vitality
Nipple sensitivity
Discharge or leaking from nipples
Breast tenderness
Loss of pubic hair
Swelling of hands, ankles, or breasts
Heart palpitations
Shortness of breath
Food /sweets /salt cravings
Increased appetite/weight gain
Tightness in neck/shoulders
Visual disturbance or decreased vision
Difficulty hearing
Diminished sense of taste
Diminished sense of smell
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