My Wellness Physicians

Chief complaint

Menopause classification Age at menarche Age at last menstrual period (if postmenopausal) Years since last period Menstrual history (if still cycling) Prior gynecologic procedures (check all that apply) Other gynecologic procedures

Primary reason for seeking HRT Treatment goals (up to 3)

Have you had the following? (check if completed; enter when and results) Have you had the following procedures? (check if yes; enter when and reason)

Check all that apply — note: some may affect HRT candidacy Other significant medical conditions

Date of last menstrual cycle Check if applicable

Current medications Supplements/vitamins

Check all that apply for each condition and family member

Other significant family history

Tobacco details (if applicable) Alcohol details (if applicable) Caffeine details (if applicable) Occupation Living situation & relationship status Social support for lifestyle changes

Drag slider to rate symptom severity: 0 = none, 10 = severe

To what extent do you enjoy physical activity? Select... Not at all Slightly Moderately Greatly Days per week of moderate to vigorous activity (last month) Select... Never 1-2x/week 3-4x/week 5+/week Duration per exercise session Select... 10 min or less 10-20 min 20-30 min > 30 min Types of activities (check all that apply) Available equipment/spaces (check all that apply) Barriers to physical activity Enjoyable activities (past or present)

Average hours of sleep per night Select... < 5 hours 5-7 hours 7-9 hours > 9 hours Usual bedtime Usual waking time Sleep issues (check all that apply)

Stress level (0-10 scale) How do you cope with stress? Mental health history (check all that apply) Current mental health treatment

Check all that apply

Vital signs & measurements Physical examination findings General: Alert and oriented. Cardiovascular: Regular rate and rhythm. Lungs: Clear to auscultation. Abdomen: Soft, non-tender. Extremities: No edema. Skin: Warm, dry, no acute lesions. Breast exam:

Clinical impression & HRT indication

HRT regimen to initiate Specific regimen details Rationale for regimen

✓ Risks, benefits, alternatives, and side effects reviewed with patient. Informed consent obtained.

Baseline labs to order FSH, Estradiol, TSH, CBC, CMP, Lipid Panel Follow-up schedule Patient education provided

Referrals (check as needed) Supplements / adjunctive therapies recommended Additional notes