OptimalJoy Wellness & Aesthetics
info@optimaljoylife.com
(865) 855-5441 Text ONLY
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Current HRT Clients Medication Refill Form
Current HRT Clients Medication Refill Form
Current HRT Clients Medication Refill Form
Current HRT Clients Medication Refill Form
HRT Follow-Up Questionnaire + Medication Refill Request
Name
(Required)
First
Last
1. How have you been feeling overall since starting or adjusting your HRT?
(Required)
Great
Good
Neutral
Poor
Very Poor
2. Any new medical diagnoses or surgeries since your last visit?
(Required)
Yes
No
If Yes, please explain:
3. Have you experienced any side effects from your hormone therapy?
None
Breast Tenderness
Bloating
Headaches
Mood Swings
Acne
Spotting
Other
Other:
4. Are you due for your lab work? (Lab work must be completed every 6 months)
(Required)
Yes
No
5. Are you currently taking your medications as prescribed?
(Required)
Yes, every day
Missed a few doses
Stopped (explain)
I stopped taking my medication because:
(Required)
The following questions are for both males and females — just answer the sections that apply to you.
(Testosterone) How is your energy and motivation?
(Testosterone) Any changes in libido or strength?
(Testosterone) Any changes in libido or strength?
(Thyroid) How is your energy overall? (better / same / worse)
(Thyroid) How is your focus or mental clarity?
(Thyroid) Any new symptoms like shakiness, heart racing, or anxiety?
(Progesterone) How has your sleep been?
(Progesterone) Any grogginess in the morning?
(Progesterone) Any changes in mood or irritability?
(Estradiol) How are your symptoms- hot flashes, sleep, mood, or vaginal dryness—since starting estradiol?
(Estradiol) Are you taking it consistently, and at what time of day?
(Estradiol) Have you noticed any side effects like breast tenderness, headaches, or nausea?
Anything else you’d like to share about how you’re feeling or changes you’ve noticed? (Optional)
What hormone(s) do you need a refill on? (Please list all that apply — testosterone, thyroid, progesterone, estradiol.)
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Main menu
Home
Services
Hormone Replacement Therapy
Medical Weight Loss
Dermal Fillers / Lips
Medical Grade Chemical Peel
Microneedling w/ RF
Liquid Lipo
Neurotoxin Treatment
Patient Resources
Patient Portal
Medication Refill Form
Hormone Replacement Therapy Interest Form
Payment Plans
Cherry Payment Plan
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Traci Carnette, NP
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