Current HRT Clients Medication Refill Form

OptimalJoy Longevity Center

info@optimaljoylife.com

(865) 855-5441 (Text Only)

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Home pageCurrent HRT Clients Medication Refill Form

Current HRT Clients Medication Refill Form

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

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

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?

(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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OptimalJoy Longevity Center in Maryville, TN provides medical-grade weight loss, hormone replacement therapy, dermal fillers, and skin treatments to help you look and feel your best.

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(865) 855-5441 (Text Only)

Office Number

info@optimaljoylife.com

By Appointment Only

Address

520 W Broadway Ave,
Maryville, TN 37801

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