PRNRX COMPOUNDING PHARMACY
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- Andra Price
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1 Male Patient Health History Form Complete the following form and mail to: PRNRx LLC, W. Liberty Lane, New Berlin, WI Or fax to: or to: To provide your healthcare provider with the most complete and individualized written recommendations, please complete, in its entirety, this form and tell us about your: Lifestyle Medical History Current Medications Symptoms Today s Date: Date of Birth: First Name: Last Name: Address: City: State Zip Code Phone (Home): Phone (Cell): Healthcare Provider s Name: Healthcare Provider s Office Phone:
2 Lifestyle PRNRX COMPOUNDING 1. Indicate your usual blood cholesterol level: Desirable (<200) Borderline high ( ) High (240+) I don t know 2. How often do you perform weight-bearing, muscle strengthening exercise for at least minutes at a time? Never Less than once a week 1-3 times weekly 4+ times per week 3. During the past year, how often have you felt excessive stress in your life? Never Occasionally Often Almost always or always 4. Which of the following best describes your level of alcohol consumption? Drinks per week: 0 to or more 5. Do you smoke? Yes No 6. Compared to an ideal weight, your current weight is: More than 10 lbs. below Within 10 lbs. +/ lbs. over lbs. over 41+ lbs. over 7. Have you broken a bone in the past 6 months? Yes No If yes, what bone(s) and when (mm/dd/yyyy)?, / / 8. If your symptoms or medical history do not indicate that one route of medication administration is better for you than another, how would you prefer your hormone replacement therapy be administered? No Preference By mouth in capsules or tablets Through the skin in creams Page 2
3 Medical History Has a healthcare provider ever diagnosed you with: 1. Benign prostatic hypertrophy? Yes / No 2. Prostate cancer? Yes / No 3. Testicular cancer? Yes / No 4. Any other types of cancer? Yes / No If yes, what type of cancer? 5. Fibromyalgia? Yes / No 6. Osteoporosis or osteopenia? Yes / No 7. Thyroid disorder? Yes / No 8. Diabetes? Yes / No 9. Epilepsy/seizure disorder? Yes / No 10. Liver disease? Yes / No 11. Gastrointestinal absorption disorder? Yes / No Page 3
4 Current Hormone Medications Please list all hormone medication taken within 24 hours before and after serum testing was performed. Hormones include: estradiol/estrogens, progesterone/progestin, testosterone, methyltestosterone, DHEA, pregnenolone, thyroid, cortisol, Vivelle-Dot, etc. Medication Strength Dosage Form Amount Frequency Exact Time Date Example DHEA.25mg/Gm Cream 2 pumps Daily 8:00am 1/1/ For Hormone Patch Users: Name or type of patch Strength: Frequency patch is changed: once/week twice/week Every other day other Date patch was last changed: (Mm/dd/yyyy) / / For Sublingual Tablet Users (check one): How many days prior to testing did you swallow your medication? 2 Days prior 1 Day prior same day Page 4
5 Other Medications, Supplements and OTC s Please list all other medications, supplements, and over-the-counter products normally taken, their dosage strength, dosage form (tablet, capsule, cream, etc.), frequency (daily, twice a day, etc.), and exact times(s) taken/applied. Medication Strength Dosage Form Amount Frequency Exact Time Date Example DHEA.25mg/Gm Cream 2 pumps Daily 8:00am 1/1/ Hormone Therapy Questionnaire 1. Are you using your hormone therapy as instructed on the bottle/package/pump jar? Yes / No If you answered No, please identify which hormone(s) and explain how you are using differently: Hormone Name I use less amount (specify amount: ) I use less frequency (specify freq.: ) I use more amount (specify amount: ) I use more frequency (specify freq.: ) Other (explain) Reason for change: Hormone Name I use less amount (specify amount: ) I use less frequency (specify freq.: ) I use more amount (specify amount: ) I use more frequency (specify freq.: ) Other (explain) Reason for change: 2. Did you stop using any hormone medication(s) Yes / No If you answered Yes, please identify which hormone(s) you stopped using and why (check all that apply): Hormone Name: Due to side-effects (specify side-effect: ) I don t feel I need it anymore Due to cost Other (explain): 3. Were you using your hormone therapy consistently for a minimum of 6-8 weeks prior to testing? Yes / No Page 5
6 Current Symptoms Using the scale from 1 to 4, please rate the level at which you experience each of the following symptoms None Minimal Moderate Severe 1. Fatigue, tired, and/or exhausted Urinary Frequency Lack or energy/endurance Depression Headaches and/or migraines Rapid mood changes/mood swings Lack of sex drive/libido/sexual desire Difficulty having/maintaining erections Hot flashes/night sweats Bloating/water retention Difficulty falling and staying asleep Memory problems/forgetfulness Loss of body hair Acne/oily skin Increased anxiety Increased irritability and/or anger Page 6
PRNRX COMPOUNDING PHARMACY
Female Patient Health History Form Complete the following form and mail to: PRNRx LLC, 17755 W. Liberty Lane, New Berlin, WI 53146 Or fax to: 1-855-957-7679 or email to: MichelleK@prnrx.com To provide
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Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
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