RenuviaMD® — BHRT Intake Form

A

About You

Basic info

First name* Please enter your first name

Last name* Please enter your last name

Date of birth* Please enter a valid date of birth (must be 18+)

Age

—

Calculated automatically

Height*

e.g., 5 ft 4 in Please enter a valid height

Weight (lb)* Please enter your weight

BMI

—

Calculated automatically

Email* Please enter a valid email address

Mobile phone* Please enter a valid 10-digit US phone number

B

Your Periods

Period & menopause status

Are you still having periods?*

Yes No Irregular

When was your last period?

Approximate date is fine — leave blank if you don't remember

Have you had a hysterectomy?*

No Yes Not sure

Have you had your ovaries removed?*

No One ovary removed Both ovaries removed Not sure

C

How Are You Feeling?

Your symptoms

Rate each symptom over the past 4 weeks.

0 = None · 1 = Mild · 2 = Moderate · 3 = Severe · 4 = Very Severe

NoneMildModerateSevereVery Severe

D

Bleeding Red Flags

Check any that apply. These help us decide if any tests are needed before starting hormone therapy.

Bleeding or spotting after my periods stopped (12+ months without a period) Very heavy or long periods recently Bleeding or spotting between periods Bleeding after sex Abnormal pelvic ultrasound or biopsy in the past year

E

Your Health History

Things we need to know

Have you ever been diagnosed with any of these?

Breast cancer Cancer of the uterus or ovaries Blood clot in leg or lung (DVT or PE) Heart attack, stroke, or "mini-stroke" (TIA) A blood clotting disorder Severe liver disease Unexplained vaginal bleeding I am pregnant or might be pregnant

Do any of these apply to you?

Migraines with vision changes (aura) Very high triglycerides Gallbladder disease or gallstones Uncontrolled high blood pressure Diabetes with eye, kidney, or circulation problems Uterine fibroids or endometriosis Abnormal breast biopsy in the past

Other ongoing conditions:

Any major surgeries?*

No Yes

Please describe (year and type)

Any allergies?*

No Yes

Please list your allergies

F

Family Health

Mother, sisters, daughters

Mother, sisters, or daughters.

G

Medications & Lifestyle

Are you currently using a GLP-1 medication? (Ozempic, Wegovy, Mounjaro, Zepbound, etc.)*

No Yes

Have you ever taken hormones? (birth control, HRT, hormone IUD, testosterone)*

No Yes Not sure

Do you smoke (cigarettes, vape, etc.)?*

No Used to, quit Yes

Do you drink alcohol?*

No Occasionally Weekly Daily

H

What You're Hoping For

Your goals

Fewer hot flashes and night sweats Better sleep Less anxiety, better mood Restore my sex drive Protect my bones Clearer thinking, less brain fog

I

Consent & Submit

1. Hot flushes, sweating
2. Heart discomfort (racing, awareness, tightness)
3. Sleep problems
4. Depressive mood
5. Irritability
6. Anxiety
7. Physical and mental exhaustion (memory, focus)
8. Sexual problems (desire, activity, satisfaction)
9. Bladder problems (urgency, leaking)
10. Vaginal dryness
11. Joint and muscle discomfort

Bioidentical Hormone Replacement Therapy (BHRT)

Before you start

Thank you

Something went wrong