EmailMe Form - ****************FEMALE SYMPTOM SHEET**************

LOCATION
PATIENT SEEN

NAME

First Last

DATE

MM / DD / YYYY

D.O.B

MM / DD / YYYY

PHONE/
TEXT

### - ### - ####

CURRENT ADDRESS

Street Address City State / Province / Region Postal / Zip Code

HAVE YOU HAD A HYSTERECTOMY OR
YOUR OVARIES
REMOVED ?

YES

NO

IF YES TYPE DATE OF SURGERY

MM / DD / YYYY

IF YOU STILL HAVE A
CYCLE, TYPE THE DATE
OF YOUR MOST RECENT

MM / DD / YYYY

CURRENT MEDICATIONS

NAME----STRENGTH-----DIRECTIONS

******PATIENT SYMPTOMS*

HOT FLASHES

NIGHT SWEATS

VAGINAL DRYNESS

URINARY LEAKAGE

FREQUENT UTI'S

PAINFUL SWOLLEN BREASTS

INSOMNIA

MOOD SWINGS

HEADACHES

NERVEPAIN

DEPRESSION

LOW LIBIDO

INABILITY TO ACHIEVE
ORGASM

PAIN DURING SEX

LOW ENERGY

WEIGHT GAIN

COLD HANDS AND FEET

LOW BODY TEMPERATURE

*USE THE FIELD BELOW TO UPLOAD A PHOTO OF YOUR LABS**

*********************************************************************

LAB FILE UPLOAD

PRESS "ADD FILE" BUTTON TO ADD YOUR LABS OR ANY OTHER RELATIVE INFO FROM YOUR COMPUTER

DOCTOR'S NAME

TYPE YOUR PHYSICIAN OR PRACTITIONER'S NAME HERE

COMMENTS OTHER
ISSUES

I hereby release the Physician, Practitioners, Wellness and Weight Loss of Fort Walton Beach, their employees, and their partners from any and ALL liability whatsoever associated with or connected to my Human Identical Hormone Therapy (also referred to herein as Bio-Identical Hormone Therapy) and/or the use of these hormones. I acknowledge that I am legally responsible and aware of the potential side-effects associated with this therapy. I understand that no Doctor, Nurse Pharmacist, or administrative personnel can guarantee that Human-Identical Hormones will provide the results I seek. I am participating in this program by my own choice, and I assume any and ALL responsibility for said outcomes. I fully understand that it is solely my responsibility to have an annual physical exam including Breast exams, PaP Smear, and/or any other lab/diagnostic testing necessary to insure my continued health and eligibility to continue on this therapy. I have been advised of any and all possible risks associated with Human-Identical Hormones including a possible increase in the chance of cardiovascular events such as Heart Attack, Stroke, Blood Clots, Pulmonary Embolus, Breast Cancer, Uterine Cancer, persistent vegetative state (coma) or even death that may possibly be related with or to my use of Human Identical Hormones.

BY CHECKING THE BOX BELOW I CONSIDER THE ABOVE DOCUMENT TO BE LEGALLY SIGNED BY ME AND I AM BOUND BY ALL STATEMENT THEREIN....

PLEASE ENTER THE DATE
YOU CHECKED/SIGNED
THE ABOVE DISCLAIMER

PLEASE SIGN USING YOUR
CURSOR TO THE BEST OF YOUR ABILITY
THIS IS MY OFFICIAL
AND LEGAL SIGNATURE

Clear

**************************PATIENT SYMPTOMS*********************

*******USE THE FIELD BELOW TO UPLOAD A PHOTO OF YOUR LABS********

******PATIENT SYMPTOMS*

*USE THE FIELD BELOW TO UPLOAD A PHOTO OF YOUR LABS**