Test and fee schedule:
Comprehensive profile: Please contact our pharmacy at 562.866.8363 for detailed information.
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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?
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Yes or No
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If yes, how often and how much?
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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.