Intake Form - Women Hormone Replacement Therapy

Country

Where Did You Hear About Us?

Hormone Replacement Therapy

This consent form will be used if you are deemed to be eligible for HRT treatment. Intellimed Wellness clinicians can deem you ineligible following their assessment.

I understand

Women's Hormone Therapy Evaluation

What is your primary reason for seeking hormone therapy? *

Are you currently having menstrual cycles? *

Have you had: *

Hysterectomy

Oophorectomy (ovary removal)

Tubal ligation

None

Age at last menstrual period (if applicable):

Have you previously used hormone therapy? (If Yes, How Long)

Do you have a history of any of the following? *

Have you had recent labs? *

Date of last labs? (If applicable)

Are you currently sexually active? *

Yes

Are you trying to conceive? *

Yes

Are you using contraception? *

Yes

Please rate the severity of the following symptoms you've experienced in the past 2 weeks using the scale:

Hot Flashes / Night Sweats *

Not at all

Mild

Moderate

Severe

Vaginal Dryness or Discomfort *

Not at all

Mild

Moderate

Severe

Decreased Libido *

Not at all

Mild

Moderate

Severe

Mood Swings and Irritability *

Not at all

Mild

Moderate

Severe

Anxiety or Nervousness *

Not at all

Mild

Moderate

Severe

Depression or Low Mood *

Not at all

Mild

Moderate

Severe

Sleep Disturbances (Insomnia) *

Not at all

Mild

Moderate

Severe

Fatigue or Low Energy *

Not at all

Mild

Moderate

Severe

Difficulty Concentration *

Not at all

Mild

Moderate

Severe

Memory Issues *

Not at all

Mild

Moderate

Severe

Weight Gain or Difficulty Losing Weight *

Not at all

Mild

Moderate

Severe

Hair Thinning *

Not at all

Mild

Moderate

Severe

Joint or Muscle Pain *

Not at all

Mild

Moderate

Severe

Headaches *

Not at all

Mild

Moderate

Severe

Urinary Frequency or Urgency *

Not at all

Mild

Moderate

Severe

How long have you been experiencing these symptoms? *

What would successful treatment look like to you? *

Heath History Questionnaire

Cardiovascular Disease *

Respiratory Disease *

Gastrointestinal Diseases *

Genitourinary Disease *

History of any of the following listed: *

History of Multiple Endocrine Neoplasia or Tumors *

Yes

Contraindications

Hormone therapy may not be appropriate for individuals with any of the following conditions. Please notify your provider if you have a history of or are currently experiencing:

General Contraindications (All Hormone Therapy)

Pregnancy, attempting pregnancy, or breastfeeding
Known hypersensitivity or allergy to any hormone or formulation component
Active liver disease or severe hepatic dysfunction
Uncontrolled cardiovascular disease
Undiagnosed abnormal vaginal bleeding

Testosterone-Specific Contraindications

Known or suspected androgen-dependent malignancy
History of polycythemia or elevated hemoglobin/hematocrit
Untreated obstructive sleep apnea
Severe acne or androgen-sensitive dermatologic conditions

Estradiol-Specific Contraindications

Known or suspected estrogen-dependent malignancy (e.g., breast or endometrial cancer)
Active or history of thromboembolic disease (deep vein thrombosis, pulmonary embolism, stroke)
Known clotting disorders or high risk for thrombosis
Uncontrolled hypertension

Progesterone-Specific Contraindications

Known or suspected breast cancer
Severe liver dysfunction
Known hypersensitivity to progesterone

List Your Prescribed Drugs and Over the Counter Drugs (Vitamins Included) *

None

Yes

(Name, Dosage, Frequency)

Allergies *

None

Yes

Exercise *

None

Mild Exercise

Occasional Vigorous Exercise

Regular Vigorous Exercise

Tobacco (including Vapes) *

Yes

Stroke:

Heart Attack:

High Blood Pressure:

Cancer:

Diabetes:

Review of Systems (Check All That Apply)

Hormone Replacement Therapy

Hormone Replacement Therapy (HRT) may include the use of testosterone, estradiol, and/or progesterone to support hormonal balance and relieve symptoms related to perimenopause, menopause, or hormone deficiency. Treatment plans are individualized based on symptoms, medical history, laboratory results, and clinical response.

The goals of therapy may include improvement in energy, mood, sleep, libido, cognitive function, body composition, and overall quality of life. Not all patients will receive all medications, and dosing may be adjusted over time.

Potential Risks & Side Effects

While many patients tolerate hormone therapy well, potential side effects may include, but are not limited to, the following:

Testosterone (Women)

Acne or oily skin
Increased facial or body hair growth
Mood changes or irritability
Fluid retention
Voice deepening or hoarseness (rare)
Clitoral enlargement (rare)
Changes in menstrual cycle
Injection site reactions (pain, redness, swelling)
Increased red blood cell count (polycythemia), which may increase the risk of blood clots

Breast tenderness or swelling
Bloating or fluid retention
Nausea or headache
Mood changes
Breakthrough or abnormal vaginal bleeding
Elevated blood pressure
Rare increased risk of blood clots, stroke, or gallbladder disease

Drowsiness or fatigue (especially when taken at bedtime)
Dizziness
Bloating
Mood changes
Breast tenderness
Irregular or breakthrough bleeding (especially with cyclic dosing)

Important Considerations

Hormone therapy may affect the body's natural hormone production and requires ongoing monitoring, including laboratory testing and clinical follow-up. Dosing adjustments may be necessary to maintain hormone levels within safe, physiologic ranges. Results are not guaranteed, and symptom improvement may vary between individuals.

I understand the potential benefits, risks, and alternatives to hormone therapy. I acknowledge that I have had the opportunity to ask questions, understand the information provided, and voluntarily consent to treatment as recommended by my healthcare provider.

Check Yes for each of the statements below, if you agree with the statement.

I consent to begin hormone therapy with Intellimed Wellness under the care of a licensed physician or nurse practitioner, based on my individual health history, labs, and clinical evaluation. *

Yes

I understand that estrogen and/or progesterone therapy, like many medical treatments, may carry potential risks. These risks can vary based on personal health history and are carefully considered before starting treatment. *

Yes

I understand that hormone therapy has been associated with a small increased risk of blood clots in certain individuals. My provider has reviewed my personal risk factors with me and will continue to monitor my health throughout treatment *

Yes

I understand that long-term hormone therapy may be associated with changes in cancer risk depending on individual factors such as age, health history, dosage, and duration of use. I acknowledge that appropriate screening and routine monitoring are an important part of safe treatment. *

Yes

I confirm that I have had, or will have, the opportunity to discuss my medical history, risks, benefits, and alternatives with the Intellimed Health Inc. and Intellimed Wellness clinical team. All of my questions have been answered to my satisfaction, and I understand that I may ask additional questions at any time before or during treatment. *

Yes

Are There Any Other Health Complications that Intellimed Wellness Should Be Aware of?

Patient Signature

Clear

By agreeing to the aforementioned terms, you authorize Intellimed Wellness to bill you on a monthly basis for refilling your prescription. You understand that it is your responsibility to call prior to the next month to cancel the membership. Please note that once billed for the month, there will be no refunds issued for membership fees.

I agree

You acknowledge that you will not hold Intellimed Wellness responsible for any self-administration of the prescribed medication?

I agree

Accuracy of Information *

I certify that the above medical information is correct to my knowledge.

Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

I agree

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the physician or nurse practitioner’s day that could have been filled by another patient. As such, we require 3 hours notice for any cancellations or changes to your appointment. Patients who provide less than 3 hours notice, or miss their appointment, will be charged a cancellation fee to the card on file.

I am aware of the Cancellation Policy.

I agree to receive promotional and appointment-related text messages from Intellimed Wellness. Message frequency varies. Msg & data rates may apply. Reply STOP to unsubscribe

I agree

I disagree

Intake Form - Women Hormone Replacement Therapy

Hormone Replacement Therapy

Women's Hormone Therapy Evaluation

Assessment

Heath History Questionnaire

Contraindications

General Contraindications (All Hormone Therapy)

Testosterone-Specific Contraindications

Estradiol-Specific Contraindications

Progesterone-Specific Contraindications

Family History

Hormone Replacement Therapy

Potential Risks & Side Effects

Testosterone (Women)

Estradiol

Progesterone

Important Considerations

Check Yes for each of the statements below, if you agree with the statement.

Monthly Billing

Self Administration

Privacy and Sharing of Information

Cancellation policy

SMS Consent