Dr Cara Flamer GSH Medical 801 Eglinton Ave West, Suite 100 Toronto, ON
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1 Dr Cara Flamer GSH Medical 801 Eglinton Ave West, Suite 100 Toronto, ON Date: Please fill out the following information for your chart profile, and bring it to your first visit (please remember you still need to bring your OHIP card to your first visit): Patient Information: Name: Address: OHIP Health Card Number: OHIP Health Card Expiry date: OHIP Health Card Version Code: Phone number: Home: Cell: address: Date of Birth: Any known allergies: Contact Person for emergencies (name, phone number): How did you hear about us?
2 Dr Cara Flamer GSH Medical 801 Eglinton Ave West Toronto ON Please fill out the questionnaire to help us create your chart profile: Current medical conditions: (please list medical diagnoses only, not symptoms) Medications you are currently taking: 6. Any hormones (non-bio-identical or bio-identical) used in past: 6. Significant past medical illness: (surgeries, hospitalizations, conditions of the past, abnormal test results from the past) 6. Allergies to medications:
3 Family history: (remember things like diabetes, heart disease, cancer- list type of cancer and age of diagnosis, thyroid disorder) Mother: Father: Siblings: Maternal aunts/uncles: Paternal aunts/uncles: Maternal grandparents: Paternal grandparents: Children: Screening tests: (please list most recent one: the month it was done and the result) Mammogram: Breast thermography: Breast ultrasound: Pelvic ultrasound: Pap smear: Bone density: Colon screening: Other physicians involved in your care: Family doctor: Naturopath: Specialist(s): Other: Social history: Are you married or in a long-term relationship? Do you have children? Do you smoke? How often do you drink alcohol? What do you do for work?
4 Dr Cara Flamer GSH Medical 801 Eglinton Ave West, Suite 100 Toronto, ON Questionnaire Hormonal Symptom Questionnaire: Estrogen/progesterone balance: (For Women Only) I have night sweats I feel hot at night (a lesser degree of a night sweat) I have hot flashes during the day (please indicate amount of flashes per day: /day) I have vaginal dryness I have a incontinence with coughing/sneezing or when I have to urinate I have an overactive bladder I have discomfort with intercourse I have insomnia- it s hard to fall asleep and/or stay asleep I am irritable and/or have a short fuse I don t feel myself anymore I am moody I feel anxious I have a history of (circle any that apply): o Fibroids ovarian cysts breast cysts endometriosis adenomysis breast/ovarian/uterine cancer o Polycystic ovaries uterine polyps My breasts are sore I feel swollen I feel sedated during the day I have problems with acne If you are still getting periods: My periods are heavy My periods are irregular I get significant PMS before my period
5 Testosterone balance: My sex drive is reduced or completely gone I feel weak I can t seem to put on muscle mass I am not as assertive as I used to be My stamina is low I have showed signs of osteoporosis or osteopenia with bone density testing I have noticed hair loss on my scalp around the frontal area and temples I have problems with acne I have bothersome amounts of hair on my arms and legs I have reduced sensation in my clitoral area/reduced sensation of orgasm Adrenal balance: I am exhausted during the day (please tell us the time of day you are most tired: ) I am wired at night; I often get a second wind if I stay up past 11pm I feel burned out I am under a lot of stress or have been for the past few years I have experienced physical or mental trauma in the past decade I feel tired but wired I have gained weight in my abdominal area I crave sugar and/or caffeine I feel like I am running on adrenaline I am exhausted after I exercise I wake up at night and can t get back to sleep I get night sweats Thyroid balance: I have a metallic taste in my mouth I have chronic fatigue, weakness, lethargy I have cold hands and feet I am intolerant to cold temperatures I suffer from constipation I feel depressed and irritable My skin is dry My nails have ridges My hair is coarse and dry I notice swelling of my eyelids or face I feel like I can t take a deep breath I have hair loss (diffusely over the scalp) or thinning hair My memory is impaired I have a history of infertility or recurring miscarriages I have insomnia I noticed my eyebrows are thinner than they used to be
6 Gastrointestinal Symptom Questionnaire: I frequently feel bloated o This relates to meals o This is unrelated to meals I am constipated o All the time o sometimes I have loose stool o All the time o sometimes I have blood in my stool I have mucous in my stool I have heartburn o sometimes o always Lifestyle Questionnaire: Diet: I eat at fast food restaurants I have dietary restrictions: o I am vegetarian o I do not eat: (pls circle all that apply) red meat fish poultry eggs o I do not eat: (pls circle all that apply) soy products wheat/gluten o Other foods i avoid: o I feel better when i avoid eating the foods mentioned above o I choose to avoid the above foods for reasons other than how i physically tolerate them I eat organic vegetables and fruit: o Sometimes o All the time I eat complex carbs (rice, pasta, bread, grains, etc) o Everyday o A few times a week
7 I eat animal protein (meat, fish, eggs, poultry) o Every day o A few times a week I eat pastries (muffins, baked goods, cakes, cookies etc) o Daily o A few times a week o Approximately once a month I drink carbonated beverages like coke, pepsi, etc I use artificial sweeteners (aspartame, Splenda) I use stevia or xylitol as sweetener I drink coffee: never occasionally daily ( cups/day) I drink alcohol: drinks per week I drink a lot of water each day Stress I have ongoing stressors in my life I often feel wired and have trouble calming down I feel easily overwhelmed by emotion I feel often feel pressed for time I have trouble falling asleep I have trouble staying asleep I wake up unrefreshed I worry a lot about specific things I worry a lot about things in general I feel irritable i feel restless i have people i can open to about the problems in my life
Medications/Supplements/Vitamins/Herbs currently taking regularly
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