1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary

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Melinda Jennings
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Tracy Dryer, RPh Sheryl Pfeiler, Pharm D, RPh 1405 NE Douglas Lee s Summit, MO 64086 Phone: 816-524-8444 Date: Fax: 816-246-5493 Female Information and Health Summary Name Date of Birth Address

1 Tracy Dryer, RPh Sheryl Pfeiler, Pharm D, RPh 1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary Name Date of Birth Address City/State/ZIP Home Phone ( )- - Cell ( )- - Fax ( )- - address Who referred you to us? Please List Your Healthcare Providers & Indicate Which Doctor to Contact Regarding Hormone Therapy Name Specialty Address Phone Fax Insurance Information: Name Specialty Address Phone Plan Name BIN# PCN# ID# Pharmacy Group# Who is the main cardholder? Your member # Fax Any Known Medication Allergies Please List Any Medications You Are CURRENTLY Taking, Including Hormones (With Strengths), Vitamins, Natural Supplements, or Non-Prescription Medications: Please List Any PREVIOUS Hormones Taken, Doses, Any Side Effects, and How Long Ago They Were Discontinued: Have You Tried Alternative Therapies or Taken Any Herbal or Homeopathic Products? 1

2 Is Your Diet: 1 Bad 2 Fair 3 Good 4 Very Good (please circle) Exercise: Type of Activity, How Frequent, and For How Long? Employer and Job Title Circle Your Perceived Stress Level: 1 None 2 Mild 3 Moderate 4 Severe 5 Extremely Severe Family History Please Check All That Apply: Cancer (type) Breast Uterine Ovarian Other Diabetes; type Heart Disease Osteoporosis Alzheimer s Disease Thyroid Disease Past or Present Medical Conditions Please check all that apply: Asthma Fibromyalgia Fractures Cancer (type: Arthritis Epilepsy Depression Varicose Veins Liver Disorder Diabetes (type: ) Kidney Disorder Headaches/Migraines Eating Disorder Thyroid Disorder Ulcers Heart Condition High Cholesterol High Blood Pressure Osteoporosis/Osteopenia Chronic Fatigue Syndrome Clotting Disorder Other Gallbladder Disease ************************************************************* Gynecological History Have You Had a Hysterectomy? Yes If Yes,When? Have Your Ovaries Been Removed? Yes If Yes, When? Have You Ever Had a Tubal Ligation? Yes If Yes, When? Have You Ever Had an Abnormal Pap? Yes If Yes, When? 2

3 Do You Perform Self-Breast Exams? Yes How Often? Obstetrical History Are You Sexually Active? Yes Are You Trying to Get Pregnant? Yes Current Method of Birth Control? How Long? Past Method of Birth Control &/or Any Problems? Have You Ever Had Children? Yes Number of Pregnancies Deliveries Multiple Births Have you ever had... (check all that apply) Sexual Problems Cervical Cancer Lack of Sex Drive Cervical Dysplasia Painful Intercourse Ovarian Cysts Vaginal Dryness Uterine Fibroids Breast Fibroids Vaginal Infections Lack of Energy HPV(vaginal warts) Pelvic Infections HSV (vaginal herpes) Inability to Reach Climax Increased Facial/Body Hair Growth Polycystic Ovary Syndrome Menstrual History Present state of Menstruation Regular Irregular Sporadic Light Heavy Periods Have You Missed Periods Altogether? Yes When Was Your Last Period? How Long is Your Cycle? Do You Have Bleeding Between Periods? Yes Have You Ever Taken Hormones Before? Yes How Did You Become Interested in Bio-Identical Hormones? Please check ALL symptoms below that apply (this is very important to the evaluation process) Symptoms of low Progesterone? Symptoms of low Estrogen? Swollen Breasts Headaches Hot Flashes Insomnia Anxiety/Irritability per week Dry Skin per week Irregular menses Cramping Foggy Thinking Heart Palpitations Infertility Acne Painful Intercourse Low Sex Drive Weight Gain Low Sex Drive Night Sweats Vaginal Dryness/Atrophy Mood Swings Depression per week Memory Lapses PMS Fuzzy Thinking Yeast Infections Depression Joint Pain Low Energy Bone Loss Headaches Food Cravings per week Symptoms of low Testosterone? Depression Urinary Incontinence Low Energy Joint Pain Low Sex Drive Bone Loss Heart Palpitations Memory Lapses Muscle Weakness 3

4 Fibromyalgia Vaginal Dryness Thinning Skin Other Symptoms Top 3 Symptoms You d Like Resolved Directions: Circle the Number That Best Describes the DEGREE of Symptom Intensity You Have Experienced Over the Past Month(s) None Mild Moderate Severe 1. Hot Flashes, Perspiration, and/or Chilly sensations? 2. Insomnia or Restless, Fragmented Sleep? 3. Irritability, Feeling Anxious or Apprehensive? 4. Feeling of Depression and Unhappiness and/or Being Miserable Without Obvious Reason? 5. Sensations of Dizziness or Swimming in the Head? 6. Feeling of Weariness of Mind and Body Associated with Desire for Rest; Disinclination to make Further Efforts? 7. Pain of Any Kind Affecting Joints or Muscles? 8. Headaches of Any Kind (Tension, Migraine, etc)? 9. Quickening or Acceleration of Heartbeat or Fluttering/Pounding Heartbeat in a Sitting or Resting Position? Have you ever had... Never Infrequently Sometimes Most of Time Always 4 1. Vaginal Burning or Itching? 4 2. Painful Urination or Increased Frequency or Urination? 4 3. Leaking of Urine When Coughing, Laughing, Sneezing, or On Hard Work? 4 4

5 4. Leaking of Urine When Walking, Running, Climbing Steps, or On Light Work? 4 5. Leaking of Urine, Regardless of Activity, Even When In a Lying Position? 4

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome: MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer