HORMONE BALANCE QUESTIONNAIRE FOR WOMEN
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1 HORMONE BALANCE QUESTIONNAIRE FOR WOMEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a personal or family history of any of the following? Uterine Cancer No Yes (relationship) Ovarian Cancer No Yes (relationship) Breast Cancer No Yes (relationship) Fibrocystic Breast No Yes (relationship) Osteoporosis No Yes (relationship) Polycystic Ovarian Syndrome No Yes (relationship) Have you had any of the following tests? Mammogram No Yes (Date) Abnormal? No Yes PAP Smear No Yes (Date) Abnormal? No Yes DEXA Scan (Bone Density Screen for Osteoporosis) No Yes (Date) Abnormal? No Yes Colonoscopy No Yes (Date) Abnormal? No Yes Since you began having periods, have you had what you consider to be abnormal cycles? No Yes If YES, please explain
2 When was your last period? How many days did it last? Did/Do you have Premenstrual Syndrome (PMS)? No Yes (Specify symptoms experienced) MEDICAL CONDITIONS / DISEASES (please check all that apply) Heart Disease (heart attack, CHF, etc.) High Cholesterol High Blood Pressure Cancer (type ) Ulcers (stomach, esophagus) Thyroid Problems Hormone Related Issues Lung Problems (asthma, COPD, etc.) Blood Clotting Problems Diabetes Arthritis or Joint Problems Depression Epilepsy or Seizure Disorder Headaches / Migraines Eye Disease (glaucoma, etc.) Liver or Gastrointestinal Disorder Other (please explain) PREVIOUS SURGERIES / HOSPITALIZATIONS (please list) How many pregnancies have you had? How many children? Have you had a hysterectomy? No Yes (date of surgery) Have you had your ovaries removed? No Yes (date of surgery) Have you had your tubes tied? No Yes (date of surgery) Please list any other surgeries you have had:
3 LIFESTYLE Do you smoke? Yes No (details) _ Do you drink alcohol? Yes No (details) _ Do you use recreational drugs? Yes No (details) _ Do you exercise? Yes No (details) _ ALLERGIES / MEDICATION INTOLERANCES (please list) I have no allergies or medication intolerances that I know of. MEDICATIONS Current Prescriptions and Over-the-Counter Medications List Hormones Currently or Previously Taken Are you currently using or have you previously used Birth Control Pills, Mirena, NuvaRing, Depo-Provera Shots or any other type of contraception? Yes No (details)
4 NUTRITIONAL SUPPLEMENTS (please circle the product you are using): Vitamins (multiple or single vitamins such as B complex, E, C, D, beta carotene, other) Minerals (calcium, magnesium, chromium, iron, zinc, copper, other) Herbs (ginseng, gingko biloba, Echinacea, medicinal teas, other) Enzymes (Digestive, papaya, bromelain, CoQ10, other) Nutritional / Protein Supplements (shark cartilage, protein powders, amino acids, fish / flaxseed oil, other) Other (please list) I do not take any nutritional supplements CURRENT SYMPTOMS For each item identified below, circle the number that best fits the symptoms you are experiencing. 0 = none 1 = mild 2 = moderate 3 = severe Hot Flashes Fibrocystic Breast Night Sweats History of Fertility Problems Difficulty Falling Asleep Cervical Dysplasia Difficulty Staying Asleep Cyclical Headaches Morning Fatigue Urinary Tract Infections Evening Fatigue Urinary Incontinence Vaginal Dryness Constipation Painful Intercourse Bone Loss Loss of Sex Drive Joint Aches and Pains Breast Tenderness Fibromyalgia
5 Depression Thinning Skin Anxiety Oily Skin Irritable Weight Gain - Hips Memory Lapses Weight Gain - Waist Tearfulness Decreased Muscle Mass Foggy Thinking Sugar / Carb Cravings Stress Unusual Sweating Hair Loss on Scalp Hoarseness Increased Facial or Body Hair Bulging Eyes Dry / Brittle Hair Slowed Reflexes Dry / Brittle Nails Cold Body Temperature Acne Blood Pressure Problems What are your goals with Bioidentical Hormone Replacement Therapy (BHRT)? Please write down any questions you have about BHRT: Patient Signature Date
HORMONE BALANCE QUESTIONNAIRE FOR MEN
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Male Hormone Questionnaire
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You may also fax, , or bring it to office ahead of time, but please bring another paper copy with you at the time of visit.
1698 Hwy 160 W., Suite 200 Fort Mill, SC 29708 P: 803-547- 4343 F: 803-547- 3914 www.infinitewellness.org Please complete the Medical History Evaluation form BEFORE you first appointment. Please remember
Hormone Consultation for Women
Healthway Compounding Pharmacy 2544 McLeod Dr. N., Ste. 2 Saginaw, MI 48604 989-791-1691 Toll Free: 866-883-8868 Fax: 989-791-4603 Hormone Consultation for Women Today s Date: / / Patient Name: Birth date:
Name: Date of Birth: Age: Address: City State Zip
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?
Medical Health Questionnaire
Medical Health Questionnaire New Patient Name Change Address Change Insurance Change ALL SECTIONS MUST BE COMPLETED FOR ALL PATIENTS: Today s Date / / Patient Name: Last First Middle Initial Date of Birth:
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
Mike Dandurand RPh. PharmD, CGP Phone # Fax # Pharmacist Progress Notes
Mike Dandurand RPh. PharmD, CGP Phone # 685-2353 Fax # 685-5331 Pharmacist Progress Notes Patient Name: Initial Evaluation Date: Address: Phone # Primary MD: MD Phone # Primary Diagnosis: Chief Complaint/Problem
Personal Data. Present Symptoms
Chris A. Pate, MD 2280 Hwy 70 West, Suite B 265 Racine Drive, Suite 102 Goldsboro, NC 27530 Wilmington, NC 28403 (919) 988-9332 Fx(919) 581-0353 (910) 399-6661 Fx(910) 399-6667 Name Personal Data Address
FEMALE SYMPTOM QUESTIONNAIRE
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PRNRX COMPOUNDING PHARMACY
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Bodily Conditions Rooted in Hormone Imbalance
Check this list for all conditions that apply to you. The total possible score is 209. Count the number of symptoms you check. The higher your score, the more likely you need to address hormone imbalances.
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THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES
abdominal pain acne aging process accelerated allergies, including asthma, hives, rashes, sinus congestion anemia (blood hemoglobin low) anorexia anovulatory (no ovulation) anxiety anxious depression appetite
Cough Suppressant (example: Robitussin DM ) Acid Blockers (examples: Tagamet HB, Pepcid AC, Zantac 75 )
$200NonRe f undabl e De pos i tdueatappoi nt me nt Sc he dul i ng! 4. Allergies: Please check all that apply: penicillin morphine dye allergies pet allergies codeine aspirin nitrate allergy seasonal (pollen)
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Accession #: Patient: Jane Doe Convert to pdf, Save or PRINT >> ADRENAL CHECK
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