Hormone Replacement Therapy Evaluation
Patient Information
Full Name
Date of Birth
Sex Assigned at Birth
Female
Male
Intersex
Current Gender Identity
Medical History
Relevant Medical History
Allergies
Current Medications
Symptoms & Indications
Symptoms or Reasons for HRT
Duration of Symptoms
Previous HRT Use
Medical Evaluation
Vitals
Relevant Lab Results
Physical Exam Findings
Assessment & Plan
Assessment
Plan (including HRT regimens discussed, risks/benefits, next steps)
Follow-up Recommendations