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PCAA Confidential Hormone Evaluation

Home » PCAA Confidential Hormone Evaluation

Step 1 of 9

11%
  • Doctor Information

  • Allergies

  • If no known allergies, please indicate N/A.
  • Over the Counter (OTC) Issues

  • Nutritional / Natural Supplements

    Please identify and list the products you are using.
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • Medical Conditions / Diseases

  • Current Prescription Medications

  • If none, please indicate "N/A" or "None".
  • If none, please indicate "N/A" or "None".
  • Family History

    Do you have a family history of any of the following:
  • Uterine Cancer
  • Ovarian Cancer
  • Fibercystic Breast
  • Breast Cancer
  • Heart Disease
  • Osteoporosis
  • Have you had the following tests performed?

  • Please answer the following questions about Menstruation as accurately as possible:

  • Enter a number only.
  • AbsentMildModerateSevere
    Fibrocystic Breast
    Weight Gain
    Heavy / Irregular Menses
    Hot Flashes
    Dry Skin / Hair
    Anxiety
    Depression
    Night Sweats
    Vaginal Dryness
    Headaches
    Irritability
    Mood Swings
    Breast Tenderness
    Sleep Disturbances / Insomnia
    Cramps
    Fluid Retention
    Breakthrough Bleeding
    Fatigue
    Loss of Memory
    Bladder Symptoms
    Arthritis
    Harder to Reach Climax
    Decreased Sex Drive
    Hair Loss
  • Consent for Treatment

  • A study called the Women's Health Initiative, involving over 160 000 women between the ages of 50-79, determined some risk of this treatment. Cardiovascular Disease: The risk of heart attacks 37 per 10 000 for women taking combination hormone therapy (estrogen +progesterone) vs 30 per 10 000 for women who did not get the combination hormone therapy. Invasive Breast Cancer: The risk of invasive breast cancer was 38 per 10 000 for women taking combination hormone therapy vs 30 per 10 000 for similar women who did not take the hormones. Strokes: The risk of stroke was 29 per 10 000 for women taking combination hormone therapy vs 21 per 10 000 for similar women who did not take hormones. Venous Thromboembolism (blood clots): the risk of blood clot was 34 per 10 000 for women who take combination hormone therapy vs 16 per 10 000 for similar women who did not take hormones. Medical science is always learning new information and this could include the discovery of other risks/benefits besides the ones listed above.
  • I wish to start Bio-Identical Hormone Replacement Therapy. I have received a full explanation of the risks/benefits. I understand different doses and mode of administration and the need to monitor routine blood/saliva testing, regular mammograms and bone mineral density tests (regular PSA and testosterone blood tests for males). I am also to report any adverse effects and follow up closely (within 3 months) while on treatment. I am to report any supplements or medication changes which Dr. Z. Sherman / Coral has functioning.

Striving for clinical excellence in the area of age prevention, wellness, relaxation and health promotion in Windsor, Ontario..

1400 Provincial Road, Windsor
(519) 969-1554
info@coralspa.com
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Mon:                 9AM – 6PM

Tue – Thu:     9AM – 8PM

Fri:                     9AM – 6PM

Sat:                    8AM – 4PM

Sun:                   CLOSED

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