REVIEW OF SYMPTOMS
If you have any of the symptoms below, please check the appropriate boxes, otherwise leave them blank !
INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPY
I have discussed the reason for taking female/male sex hormones with my provider. I understand why he/she is prescribing them, and the risks associated with taking hormones including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are risks if I take any medication, including HRT. I have discussed these risks and the reasons for taking them, with my provider and I want to proceed with therapy. I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT, and I agree to follow the ultimate advice and recommendations of my provider. I understand that Hormone therapy is very individualized and that there are no guarantees that these measures will be effective, and I am participating in this therapy with that understanding. I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them and guide me through a therapy for me.