Hormone Therapy Screening & Consent

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Patient Information

Basic identifying information

Legal First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Today's Date *

State Where You Will Be Located During Visits *

Primary Reason for Seeking Hormone Therapy *

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Required Pre-Treatment Screening

The following must be completed or on file before hormone therapy is initiated

ⓘ Why these are required: Breast imaging screens for occult malignancy before initiating estrogen. Labs establish your baseline hormone levels, metabolic health, and identify contraindications. These are standard of care requirements — not optional.

📄 Mammogram OR Breast Ultrasound

Required within the past 12 months for patients 40+ or within 24 months for patients 35–39. Breast ultrasound is acceptable if mammography is contraindicated or inconclusive. Results must be available at time of consultation.

Date of most recent:

Result:

⚠ Flag: Abnormal mammogram or pending biopsy is a temporary contraindication to hormone initiation. Please contact us before proceeding.

🧪 Complete Lab Panel

Labs must be drawn within 90 days of your consultation. Required: CBC, CMP, lipid panel, HbA1c, TSH, free T4, estradiol, progesterone, testosterone (free + total), DHEA-S, FSH, LH, vitamin D. Additional markers may be ordered based on history.

Labs drawn on:

Where were labs drawn?

📋 Uterus Status — Required for Progesterone Prescribing

If you have a uterus, you must receive progesterone alongside estrogen. Estrogen alone (unopposed) in the presence of a uterus significantly increases endometrial cancer risk.

I have a uterus (intact)

Hysterectomy (complete)

Partial hysterectomy

🕐 Menopause / Hormonal Status

Perimenopause (irregular cycles, symptoms beginning)

Postmenopause (>12 consecutive months without period)

Surgical menopause (ovaries removed)

Premenopausal (regular cycles)

Date of last menstrual period (approx):

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Cardiovascular & Clotting Risk Screening

Blood clot and cardiovascular history are critical safety screens — please answer every question accurately

Answer YES or NO to each question. A YES does not automatically disqualify you, but may affect which hormones, doses, or delivery methods are appropriate.

Have you ever had a blood clot (DVT — deep vein thrombosis) in your leg?

Yes No

⚠ Clinical note: History of DVT is a contraindication to oral estrogen. Transdermal estrogen may be considered after thorough evaluation and thrombophilia workup.

Have you ever had a pulmonary embolism (blood clot in the lungs)?

Yes No

⚠ Clinical note: Pulmonary embolism history is a significant contraindication to hormone therapy. Individual risk-benefit analysis and hematology clearance required.

Have you been diagnosed with a clotting disorder (e.g., Factor V Leiden, antiphospholipid syndrome, protein C/S deficiency)?

Yes No

⚠ Clinical note: Known thrombophilia is a relative-to-absolute contraindication. Hematology co-management required.

Have you ever had a stroke or TIA (transient ischemic attack)?

Yes No

⚠ Clinical note: History of stroke or TIA is a relative contraindication to estrogen. Neurologist clearance and transdermal-only route required if proceeding.

Have you ever had a heart attack (myocardial infarction)?

Yes No

⚠ Clinical note: Hormone therapy initiation within 1 year of MI is contraindicated. Cardiology clearance required after 1 year.

Do you have known coronary artery disease, heart failure, or uncontrolled hypertension?

Yes No

Do you currently smoke cigarettes or tobacco products?

Yes No

⚠ Clinical note: Active smoking significantly increases blood clot, stroke, and cardiovascular risk with estrogen. Oral estrogen is contraindicated in active smokers. Transdermal carries lower risk. Smoking cessation counseling will be provided.

Have you quit smoking within the past 12 months?

Yes No

Cardiac / Vascular History Details (if any YES answers above, describe)

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Cancer History & Family History

Hormone-sensitive cancer history affects eligibility for hormone therapy

Have you ever been diagnosed with breast cancer?

Yes No

⚠ Absolute contraindication: History of breast cancer is generally an absolute contraindication to systemic hormone therapy. Vaginal estrogen (low-dose local) may be considered with oncology approval.

Have you ever been diagnosed with endometrial (uterine) cancer?

Yes No

⚠ Clinical note: History of endometrial cancer requires thorough evaluation. Gynecology/oncology clearance required before any estrogen initiation.

Have you ever been diagnosed with ovarian cancer?

Yes No

Have you had BRCA1/BRCA2 genetic testing? If yes, result:

BRCA+ (mutation) BRCA- (negative) Not tested

Do you have 2 or more first-degree relatives (mother, sister, daughter) diagnosed with breast cancer?

Yes No

Cancer / Family Cancer History Details

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Medical History & Current Conditions

Check all that apply

Do you have unexplained vaginal bleeding in the past 6 months (postmenopausal)?

Yes No N/A

⚠ Absolute contraindication: Unexplained postmenopausal bleeding must be fully worked up with gynecologic evaluation before hormone therapy can be initiated.

Other Medical Conditions Not Listed Above

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Current Medications & Supplements

Including OTC products, herbals, and any current or past hormone therapy

Are you currently taking any prescription medications?

Yes No

List all prescription medications (name, dose, duration)

Are you currently taking anticoagulants (warfarin, Eliquis, Xarelto, heparin)?

Yes No

Are you taking herbal/OTC products for hormonal symptoms (black cohosh, red clover, wild yam)?

Yes No

Have you used hormone therapy (estrogen, progesterone, or testosterone) in the past?

Yes No

Previous hormone therapy details (if applicable)

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Risks & Benefits of Hormone Therapy — Informed Consent Disclosure

Please read carefully. You will be asked to confirm you have read and understood this section

ⓘ The information below reflects current evidence from NAMS, ACOG, and the USPSTF. BHRT uses hormones chemically identical to those produced by the human body (17-beta estradiol, micronized progesterone, testosterone). Bioidentical does not mean risk-free. All hormones carry risks that must be understood.

🚫 Absolute Contraindications — Hormone Therapy Cannot Be Initiated

Active or history of breast cancer (ER-positive or unknown)
Active or history of endometrial cancer (unopposed estrogen)
Active or undiagnosed vaginal bleeding
Active DVT or pulmonary embolism
Active liver disease or liver failure
Known estrogen-sensitive tumor (gynecologic or other)
Pregnancy (confirm negative prior to initiation)

⚠️ Relative Contraindications — Risk-Benefit Analysis Required

Personal history of DVT/PE (>12 months ago, now off anticoagulation)
Active cigarette smoking (oral estrogen contraindicated; transdermal options much lower risk)
Migraines with aura (increased stroke risk with oral estrogen)
Uncontrolled hypertension (must be controlled before initiation)
Strong family history of breast cancer (2+ first-degree relatives, or BRCA+ carrier)
Known thrombophilia (e.g., Factor V Leiden)
Gallbladder disease (oral estrogen risk; lower with transdermal)
Hypertriglyceridemia (oral estrogen may worsen; transdermal preferred)

⚠️ Potential Risks

Breast cancer: Combined estrogen + synthetic progestin associated with modestly increased risk after 3–5 years. Micronized progesterone (bioidentical) shows lower risk profile. Moderate
Blood clots (DVT/PE): Oral estrogen increases risk 2–4x. Transdermal estrogen carries minimal increase. Risk higher with obesity, immobility, thrombophilia. High oral Low transdermal
Stroke: Modest increase with oral estrogen, particularly in women over 60 or >10 years post-menopause. Transdermal estrogen has no demonstrated stroke risk increase. Moderate oral
Endometrial cancer: Estrogen alone without progesterone in women with a uterus significantly increases endometrial cancer risk. Progesterone co-therapy eliminates this risk. High if unopposed
Cardiovascular events: Starting HRT within 10 years of menopause or before 60 appears neutral or favorable. Starting >10 years post-menopause may increase cardiac risk ("timing hypothesis"). Timing dependent
Gallbladder disease: Oral estrogen increases gallstone risk. Transdermal route much lower risk. Low transdermal
Common side effects: Breast tenderness, bloating, mood changes — usually dose-related and temporary. Low
Testosterone-specific risks: Acne, hair growth, voice changes, clitoral enlargement, polycythemia. Dose monitoring required. Low when monitored

✅ Established Benefits

Vasomotor symptom relief: Most effective treatment for hot flashes and night sweats. Reduces frequency and severity by 75–90% in most women. FDA-approved indication.
Bone density preservation: Estrogen prevents osteoporosis and reduces fracture risk. Highly effective when started in early menopause.
Genitourinary health: Resolves vaginal atrophy, dryness, painful intercourse, reduces recurrent UTI risk (GSM).
Mood and mental health: Reduces depression, anxiety, and mood instability from hormonal fluctuations. Particularly beneficial in perimenopause.
Sleep quality: Improves sleep by reducing night sweats and stabilizing estrogen levels regulating sleep architecture.
Cognitive function: Observational data suggests potential protective effect against Alzheimer’s when started in perimenopause/early menopause.
Cardiovascular protection (early): Women starting within 10 years of menopause may have neutral or favorable cardiovascular and metabolic effects.
Testosterone benefits: Improved libido, energy, lean muscle mass, cognitive sharpness, and wellbeing (off-label use in women).
Skin and collagen: Preserves skin elasticity and collagen content, reduces thinning associated with menopause.

ⓘ Route of administration matters: Transdermal estrogen bypasses first-pass liver metabolism — significantly lower risk of blood clots, gallbladder disease, and stroke vs. oral. Vaginal estrogen (local low-dose) carries minimal systemic absorption and is generally safe in most women. Your provider recommends the safest route based on your individual risk profile.

ⓘ About the WHI: The 2002 Women’s Health Initiative study used oral conjugated equine estrogen + synthetic medroxyprogesterone acetate in women averaging 63 years old (13 years post-menopause). Subsequent analysis found the absolute risk increase was small and that younger women starting earlier have a fundamentally different risk profile. Current NAMS and ACOG guidelines affirm that for healthy women under 60 or within 10 years of menopause, benefits generally outweigh risks.

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Your Goals & Questions

Help us understand what matters most to you

What symptoms are most affecting your quality of life?

What are your primary goals from hormone therapy?

Do you have concerns or hesitations about hormone therapy?

Delivery method preference (if any)

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Informed Consent & Patient Attestation

Required — please read each statement and confirm

Check each box to confirm your understanding. Your electronic signature below constitutes your informed consent.

I have read and understand the Risks & Benefits section (Section 7) and have had the opportunity to ask questions.

I understand that hormone therapy is not right for everyone and that my eligibility will be determined by my provider based on my complete medical history, labs, and imaging.

I have answered all questions truthfully and completely. I understand that withholding information could result in prescribing decisions that harm me.

I understand that mammography/breast imaging and up-to-date labs are required before hormone therapy is initiated, and I agree to provide results as directed.

I understand that hormone therapy requires ongoing monitoring with periodic labs (every 3–6 months), follow-up visits, and may need dose adjustments over time.

I understand that Florida Mobile Health prescribes only FDA-approved brand-name medications. No compounded hormones are used unless specifically discussed and clinically justified.

I understand this form does not create a provider-patient relationship. A clinical evaluation is required before any treatment is initiated.

I consent to Florida Mobile Health maintaining this health information as part of my confidential medical record, consistent with HIPAA regulations.

I acknowledge I may withdraw consent for hormone therapy at any time, and that discontinuation may require a tapering plan to avoid abrupt withdrawal symptoms.

Patient Electronic Signature

By signing below, I attest that: (1) I have read this entire form; (2) I have answered all questions accurately; (3) I understand the risks, benefits, alternatives, and contraindications of hormone therapy as described; (4) I have had the opportunity to ask questions; and (5) I provide informed consent to proceed with a hormone therapy evaluation with Michele Li Causi, FNP-BC, of Florida Mobile Health.

I acknowledge that this consent does not guarantee that hormone therapy will be prescribed — final prescribing decisions rest with the clinician following full evaluation. This is a telehealth practice and applicable telehealth consent laws of my state apply.

Patient Full Legal Name (typed signature)

Date

📋 For Provider Use Only

Date Form Reviewed

Screening Status

Provider Initials

Provider Clinical Notes

This form was developed in accordance with current NAMS, ACOG, and evidence-based hormone therapy prescribing guidelines. It does not constitute legal advice. Florida Mobile Health recommends annual review of all clinical consent forms with your malpractice carrier and a licensed healthcare attorney. All services are provided by Michele Li Causi, FNP-BC, RD, CDCES — licensed for autonomous practice in Florida and licensed in Arizona, Nevada, Colorado, New Mexico, and Utah.

Patient Access Required

Patient Information

Required Pre-Treatment Screening

📄 Mammogram OR Breast Ultrasound

🧪 Complete Lab Panel

📋 Uterus Status — Required for Progesterone Prescribing

🕐 Menopause / Hormonal Status

Cardiovascular & Clotting Risk Screening

Cancer History & Family History

Medical History & Current Conditions

Current Medications & Supplements

Risks & Benefits of Hormone Therapy — Informed Consent Disclosure

🚫 Absolute Contraindications — Hormone Therapy Cannot Be Initiated

⚠️ Relative Contraindications — Risk-Benefit Analysis Required

⚠️ Potential Risks

✅ Established Benefits

Your Goals & Questions

Informed Consent & Patient Attestation

Patient Electronic Signature

📋 For Provider Use Only