Test and fee schedule:

Comprehensive profile: Please contact our pharmacy at 562.866.8363 for detailed information.

Hormone Symptoms Key
Fibrocystic breast + E
 – P
Weight gain
 + E – P
Heavy/Irregular cycle + E – P
Hot Flashes – E – P ^ E
Dry skin/hair – E
Anxiety – E – P
Depression – E + P – T + C – TH
Night sweats – E ^ C
Vaginal dryness – E – T
Headaches ^ E ^ P – T
Irritability + E ^ P
Mood swings + E – P
Breast tenderness – P + E
Insomnia/sleep disturbances – P – E + T
Cramps – P
Fluid retention – P + E
Breakthrough bleeding – P
Fatigue – T – TH + P – C
Memory loss – T – E
Bladder symptoms – E – T
Arthritis – T – P
Harder to reach climax – T – E – P
Decreased sex drive – T + E – C – TH
Hair loss + T ^ TH ^ E ^ P
E=Estrogen P=Progesterone T=Testosterone C=Cortisol TH=Thyroid
+=High -=Low ^=Fluctuating Levels
Please feel free to call one of our pharmacists if you have any questions.
Hormone Replacement Consultation with one of our compounding pharmacists that have extensive training and experience.
Information that will be covered during the consultation
  1. Medical history

2. Family history diseases related to natural hormone replacement

a. –Cancer 
b. –Osteoporosis
c. –Heart disease

3. Lifestyle changes related to natural hormone replacement

a. –Tobacco/alcohol
b. –Diet
c. –Exercise
  4. HRT (Bio-identical Hormone Replacement Therapy)

5. Life Stages

a. –Menopause —Pre menopause 
b. –Perimenopause –Andropause
6. Vitamin Supplements
7. Dosages of HRT for different life stages
8. Saliva testing (optional)
9. Final recommendation
10. Follow up—Triad–newsletter—direct mail
Medical History Form
Please bring your form with you when you meet with the pharmacist.

Patient Information:                                                          Today’s date: _______________

Name: _____________________________________      Birthdate: ___________________
Address: ____________________________   City: ___________ State: ____ Zip: _______
Home # ______________ Work # _______________ Email address: _________________
Payment type: ______ Credit card (MC/Visa/Discover) Cash: ______ Other: ____________
Insurance: _________________ ID # _________________ Group # __________________
Referred by____________________________
Doctor information: Are you currently under the care of a physician?  Yes _____ No _____
If yes, please list each doctor from whom you seek care:
Doctors name: ________________________ Phone # _____________________
Doctors name: ________________________ Phone # _____________________
Pharmacy Information: Are you using any other pharmacy? Yes _____ No _____
Pharmacy name _______________________ Phone # _____________________
Pharmacy name _______________________ Phone # _____________________

Lifestyle information:

Do you use?
Yes or No
If yes, how often and how much?
Tobacco (smoke, chew, dip)
Alcohol (beer, wine, hard liquor)
Caffeine (cola drinks, tea, coffee)

Do you exercise regularly? Yes: __________ No: ____________
If yes, describe what you do and how often: ______________________________________
Diet:  Describe your typical daily food intake:
First meal: ________________________________________________________________
Second meal: _____________________________________________________________
Third meal: _______________________________________________________________
Any snacks/others: _________________________________________________________
Medical status:
General Health: Excellent: ___ Good: ___ Fair: ____ Poor: ___ Height: ____ Weight: ____
Medical conditions/Disease: Please check all that apply to you:

__ Heart disease __ Lung condition __ High cholesterol
__ Cancer __ Ulcer __ Thyroid disease
__ Hormone related issues __ Blood clotting problems   __ Diabetes
__ Arthritis/Joint problems  __ Depression    __ Epilepsy
__ Headaches/Migraines __ Eye disease  __ Others: Please list: 

___________________________________________
Current prescription medication ___________________________________________
____________________________________________________________________
OTC Medications:

__ Pain reliever/ Aspirin __ Non steroidal anti-inflammatory __ Decongestants
__ Cough suppressants __ Antihistamines  __ Cough and cold combinations
__ Sleep aids __ Antidiarrheals __ Laxatives/Stool softeners
__ Diet aids __ Antacids   __ Acid blockers

List types (ex: Rolaids): __________________________________________________
Allergies: Please check all that apply
__ Penicillin    __ Morphine    __ Dye    __ Pets    __ Codeine    __ Aspirin    __ Nitrate        __ Sulfa drugs    __ Food allergies    __ Seasonal (pollen)    __ No known allergies            __ Others: Please describe when your reaction occurred and what you experienced: __________________________________________________________________________________________________________________________________________________
Childhood diseases: ________________________________________________________
Family history: Please list family members and relatives that may have important diseases such as high blood pressure, heart disease, cancer, diabetes, osteoporosis, etc. _________________________________________________________________________
Have you ever had your cholesterol level checked: ____ Date: _______ Results:_________
Have you ever had a mammogram: _____ Date: ________ Results: __________________
Have you ever had a bone density scan: _____ Date: _______ Results: _______________
Have you had your thyroid levels taken recently: _____ Date: ________ Results:_________
How did you arrive at the decision to consider prescription natural hormone replacement therapy?
Doctor: __________ Self: ___ Friend/Family member: __________ Other:__________
Have you ever used oral contraceptives: ___No___Yes  If yes, how long ______
Any problems ___Yes___No
How many pregnancies have you had? __________ How many children? ________
Have you had a hysterectomy: ___ Yes  ___No  If yes, date of surgery ___________
____Total ___Uterus only
Have you had a tubal ligation: ___ Yes ___No
Date of last pelvic exam: ____________  and pap smear: ______________
Age at first period: ____________
Since you first began having periods, have you ever had what you would consider to be abnormal cycles?  ___ No  ___Yes  If yes, please explain (age when occurred and symptoms): ________________________________________________________
_________________________________________________________________________
When was your last period: ___________________
How many days did it last? ___________________
Have you ever had Premenstrual Syndrome (PMS): ___ No  ___ Yes
If yes, explain symptoms: ____________________________________________________________
What are your goals for Bio-identical Hormone Replacement Therapy?________________________
_________________________________________________________________________________
What dosage form do you prefer? ___Cream  ___Capsules  ___Lozenges  ___Other
SYMPTOMS                             None               Mild           Moderate         Severe
Hot flashes                               ______          ______          ______          ______
Night sweats                            ______          ______          ______          ______
Vaginal dryness                       ______          ______          ______          ______
Incontinence                            ______          ______          ______          ______
Foggy thinking                        ______          ______          ______          ______
Memory lapse                          ______          ______          ______          ______
Tearful                                     ______          ______          ______          ______
Depressed                                ______          ______          ______          ______
Heart palpitations                    ______          ______          ______          ______
Bone loss                                 ______          ______          ______          ______
Sleeplessness                           ______          ______          ______          ______
Headaches                               ______          ______          ______          ______
Aches and pains                      ______          ______          ______          ______
Fibromyalgia                           ______          ______          ______          ______
Morning fatigue                      ______          ______          ______          ______
Evening fatigue                       ______          ______          ______          ______
Allergies                                  ______          ______          ______          ______
Sensitivity to chemicals          ______          ______          ______          ______
Stress                                       ______          ______          ______          ______
Cold body temperature           ______          ______          ______          ______
Sugar cravings                        ______          ______          ______          ______
Elevated triglycerides             ______          ______          ______          ______
Weight gain–waist                  ______          ______          ______          ______
Decreased libido                     ______          ______          ______          ______
Loss of scalp hair                    ______          ______          ______          ______
Increased facial or body hair  ______          ______          ______          ______
Acne                                       ______          ______          ______          ______
Mood swings                          ______          ______          ______          ______
Tender breasts                         ______          ______          ______          ______
Bleeding changes                    ______          ______          ______          ______
Nervous                                   ______          ______          ______          ______
Irritable                                    ______          ______          ______          ______
Anxious                                   ______          ______          ______          ______
Water retention                        ______          ______          ______          ______
Fibrocystic breasts                   ______          ______          ______          ______
Uterine fibroids                        ______          ______          ______          ______
Weight gain–hips                    ______          ______          ______          ______
Cystic ovaries                          ______          ______          ______          ______
Endometriosis                         ______          ______          ______          ______

**Please bring completed form with you for your consultation with a compounding pharmacist.
All pharmacist consultations include evaluation and interpretation of symptoms, dietary recommendations, lifestyle recommendations and a suggestive initial dosing of HRT with follow up evaluations and recommendations.