2005 Automobile Expenses – Physicians Compounding Pharmacy ...
PHYSICIANS COMPOUNDING PHARMACY
CONFIDENTIAL HORMONE EVALUATION
MEDICAL HISTORY
Today’s Date:___________
Name:_________________________________ Birthdate:________ Age:_______
Address:_____________________________________________________________
City:_________________________________ State:__________ Zip:________
Phone:_______________________________ E-Mail Address:___________________
Gender: Male ________ Female ________ Ht:_________ Wt:__________
How often and how much?
Do you use tobacco? Yes ____ No ____ ________________________________
Do you use alcohol? Yes____ No ____ ________________________________
Do you use caffeine? Yes____ No ____ ________________________________
Doctor’s Name: City: Phone: _______
Allergies: Please check all that apply ____ no known allergies
____ penicillin ____ morphine ____iodine/dye ____ pets
____codeine ____ aspirin ____ nitrate ____ seasonal
____ sulfa ____ food Other_____________________________
Please describe the allergic reaction you experienced and when it occurred
Over the counter products (OTCs) used:
____ aspirin ____ cough and cold relievers
____acetaminophen ____ antidiarrheals (lomotil, imodium, kaopectate)
____ ibuprofen (Motrin) ____ laxatives/stool softeners (doxidan, correctol)
____naproxen (Aleve) ____ diet aids/weight loss products
____ketoprofen (Orudis) ____antacids (tums, mylanta, maalox)
____antihistamines ____ acid blockers (zantac, tagamet, pepcid)
____ decongestants
Other:________________________________________________________________
Page 1
Nutritionals/Supplements/Vitamins:
____ Multiple vitamins, including b-complex
____ Minerals (calcium, magnesium, chromium)
____ Herbs (Ginseng, Gingko biloba, adaptogens for adrenal fatigue)
____ Enzymes (digestive enzymes)
____ Probiotics
____ Protein supplements (energy drinks, bars, meal replacements)
____ Fish oil
____Other _______________________________________________________
Medical Conditions/Diseases:
____heart disease (congestive heart disease) ____ blood clotting problems
____high cholesterol or lipids ____ diabetes
____high blood pressure ____ arthritis or joint problems
____ cancer ____ ulcers
____depression ____thyroid disease
____headaches/migraines ____hormonal related issues
____ eye disease ____lung conditions (COPD, asthma)
____ Other_________________________________________________________
Current Prescription Medications:
Medication Name Strength How often per day Date started
List Hormones Previously Taken Date started Date stopped Reason
Have you ever taken oral contraceptives? Yes______ No _______
If yes, any issues with them ________________________________________
Bone Size small _________ medium ___________ large ___________
Body Type: masculine __________ feminine __________
Patient Name:____________________________________
Page 2
How many pregnancies have you had? __________ How many children?________
Have you had a hysterectomy? Yes _____ No _____ If yes, date _________
Ovaries removed? Yes _____ No _____
Have you had a tubal ligation? Yes _____ No _____ If yes, date__________
Do you have a history of any of the following?
Uterine cancer ___________ Family member(s) ___________________
Ovarian cancer___________ Family member(s) ___________________
Fibrocystic breasts___________ Family member(s) ___________________
Breast disease ___________ Family member(s) ___________________
Heart disease ___________ Family member(s) ___________________
Osteoporosis ___________ Family member(s) ___________________
Have you had any of the following tests performed? Check those that apply and indicated the date of the last test.
Mammography Yes_______ No________ Date: ________________
PAP Smear Yes _______ No ________ Date:________________
Since you first began having periods, have you ever had what you consider to be an abnormal cycles?
If yes, please explain (such as what age this occurred, symptoms, etc):
When was your last period?________________________________________
How many days did it last?_________________________________________
Do you have or did you ever have Premenstrual Syndrome (PMS)? Yes_____No_______
If yes, please explain symptoms:
What are your goals with Bio-Identical Hormone Replacement Therapy?
What Questions do You have?
________________________________________________________________________
Patient Name:________________________________ Page 3
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- 2005 automobile expenses physicians compounding pharmacy
- magellan rx management
- department of veterans affairs pbm user manual
- the prevention of medical errors
- over the counter o t c medications
- title gastroesophageal reflux disease
- zantac recall city gps wellington new zealand
- pediatric care guide
- advance care planning and the love song of j alfred
- chapter 5 drugs for neoplastic disorders
Related searches
- po box 2005 greenville tx
- 2005 events timeline
- 2005 events in america
- year 2005 events timeline
- 2005 f150 5 4 engine diagram
- major events 2005 2015
- major events from 2005 to present
- 2005 major events in america
- important events in 2005 in usa
- 2005 ford 4 6 engine specs
- historical events in 2005 2010
- significant events 2005 present