Hormone Health — Baseline Assessment

Hormone Health — Baseline Assessment

Tell us how you feel and what you would like help with. Choose Unknown when you are not sure. Leave optional questions blank rather than guessing. Your care team can help. This form is not an emergency service.
What is your Healthie patient ID?
This baseline records your starting point for care-team review. Complete it at the start or when your care team requests a new baseline. Answer each question for its stated timeframe; leave optional unknown results blank.
Assessment Details
Assessment date
Use year-month-day, for example 2026-09-07.
Which age group are you in?
under_18 = under 18; adult_18_64 = 18 to 64; adult_65_plus = 65 or older; unknown = I am not sure.
Do you agree to share these answers with your care team for review?
Who is filling out this form?
self = I am answering for myself; caregiver = I am helping someone; clinician = I am a care-team member; unknown = I am not sure.
Safety First

This form is not an emergency service. For an emergency, call 911. Do not wait for a reply to this form.
Are you having chest pain or severe trouble breathing right now?
Do you think you need emergency medical help right now?
Are you in danger of being hurt by someone right now?
Are you at risk of hurting yourself right now?
Are you bleeding heavily or showing signs of severe dehydration?
Have you suddenly developed severe weakness or trouble speaking, seeing, or walking?
Are you having a severe allergic reaction right now?
Symptoms & Daily Function

Tell us what has been bothering you. Choose Unknown when you are not sure.
Have you had unusual vaginal bleeding?
Have you recently been ill?
Are you concerned about symptoms that may be related to testosterone?
Are you concerned about weak bones or bone loss?
Has it become harder to do your usual daily activities?
Are menopause symptoms bothering you?
In the past 7 days, on how many days could you take part in your usual activities?
Enter 0 to 7. Think of your usual home, work, school, social, or enjoyable activities.
Which symptom or daily activity matters most to track?
Are you concerned about polycystic ovary syndrome, also called PCOS?
How much are your symptoms bothering you?
0 = symptoms are not bothering you. 10 = symptoms are bothering you as much as you can imagine.
Has your care team told you that you have Hashimoto's or Graves' disease?
Are you concerned about your thyroid?
Which stage best describes you?
reproductive = before the menopause transition; perimenopause = around the menopause transition; postmenopause = after menopause; not_applicable = does not apply; unknown = I am not sure. Your care team can help.
Care Plan & Treatment

Tell us about changes or problems. Do not change a medicine because of this form.
In the past 7 days, on how many days did you follow your care plan?
Enter 0 to 7. This is about your agreed care plan, not how many doses of one medicine you took. Leave blank if you do not have a plan yet.
What have you tried, and what helped or did not help?
What could make your care plan difficult to follow?
Do you take biotin, including in hair, skin, or nail vitamins?
Are you currently taking hormone medicine?
Have any of your medicines or doses changed?
Have you noticed problems that might be caused by a medicine, supplement, or treatment?
Are you pregnant or breastfeeding?
Goals & Support

Think about what you would most like help with.
Would you like help with fertility or planning a pregnancy?
How much progress have you made toward your main goal?
0 = no progress yet. 10 = your goal is fully reached. Leave blank if you have not set a goal yet.
Has your current care plan not helped yet?
What would meaningful progress look like in 90 days?
What is the main change you would like to achieve?
Have you told your care team what you would like to improve?
What would you most like help with?
function = daily activities; symptom_burden = fewer symptoms; risk_management = lowering health risks; participation = doing more of what matters to me; care_coordination = help organizing care; unknown = I am not sure.
Recorded Results (Optional)

Skip optional results you do not know. Do not calculate a score or perform a new test. Your care team can help.
Has your care team told you that your test results have improved?
Recorded result dates and sources
Record each result name, date, source and unit exactly as shown in your records; skip unknown results.
Were your recent measurements taken in a different way than before?
What TSH thyroid result is shown on your lab report?
Optional. Copy your TSH result in mIU/L from your report.
Care team check: allergy information
Care team check: diagnosis records
Care team check: medicine list
Care team check: mood questionnaire score
For your care team to complete. You do not need to calculate a score or verify clinical records.
Care team check: permission for a helper to answer
Care team check: vitamin and supplement list
Secure intake access code
Submission mode - clinical or internal fictional test
Should be Empty:

Hormone Health — Baseline Assessment

Assessment Details

Safety First

Symptoms & Daily Function

Care Plan & Treatment

Goals & Support

Recorded Results (Optional)