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 your healthcare provider with the most complete and individualized written recommendations, please complete, in its entirety, this form and tell us about your: Menstrual and Reproductive History 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): Email: Healthcare Provider s Name: Healthcare Provider s Office Phone:
Menstrual and Reproductive Information 1. When was your last menses/period? (mm/dd/yyyy) / / 2. Are you still having periods/menstruating? Yes / No / Unsure 3. How many ovaries do you have? Both (2) One (1) None (0) 4. Have you had a hysterectomy? Yes / No / If yes, when was the hysterectomy? (mm/dd/yyyy) / / 5. Have you had an endometrial ablation? Yes / No 6. How many periods have you had in the last 12 months? None 1-3 4-8 9-12 13+ 7. Are/were your menstrual cycles regular (within 3 days variation of cycle) Yes / No 8. Have you gone a full 12 months or more without a period? Then experienced episodes of vaginal bleeding? Yes / No If yes, when did this last occur? If yes, how many times did this bleeding occur? 9. Are you currently pregnant? Yes / No 10. Are you planning or trying to become pregnant? Yes / No 11. Have you delivered a baby in the past 6 months? Yes / No 12. Are you currently breast feeding? Yes / No Page 2
Lifestyle 1. Indicate your usual blood cholesterol level: Desirable (<200) Borderline high (200-239) High (240+) I don t know 2. How often do you perform weight-bearing, muscle strengthening exercise for at least 15-20 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 2 3 7 8 14 15 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. +/- 11-20 lbs. over 21-40 lbs. over 41+ lbs. over 7. Your Current: Height: Weight: lbs. 8. Have you broken a bone in the past 6 months? Yes No If yes, what bone(s) and when (mm/dd/yyyy) / / 9. 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 3
Medical History Has a healthcare provider ever diagnosed you with: 1. Osteoporosis or osteopenia? Yes / No 2. Thyroid disorder? Yes / No 3. Diabetes? Yes / No 4. Epilepsy/seizure disorder? Yes / No 5. Liver disease? Yes / No 6. Gastrointestinal absorption disorder? Yes / No 7. Fibrocystic breast changes? Yes / No 8. Ovarian cysts? Yes / No 9. Uterine fibroids? Yes / No 10. Endometriosis? Yes / No 11. Breast cancer? Yes / No 12. Ovarian cancer? Yes / No 13. Cervical cancer? Yes / No 14. Uterine cancer? Yes / No 15. Polycystic ovary syndrome (PCOS)? Yes / No 16. Do you experience vaginal / yeast infections more than 4 times/year? Yes / No 17. Heart attack / myocardial infarction? Yes / No 18. Blood clots / DVT (deep vein thrombosis)/embolism? Yes / No 19. Stroke / cerebral vascular accident? Yes / No Page 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 1/1/15 1. 2. 3. 4. 5. 6. 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 For Oral Contraceptive/Birth Control Users (check one): I intend to continue using oral contraceptives and I continued using during saliva sample collection. I chose to stop using oral contraceptives for 2-3 cycles prior to testing. Page 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 1/1/15 1. 2. 3. 4. 5. 6. 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 6
Current Symptoms Using the scale from 1 to 4, please rate the level at which you experience each of the following symptoms. 1 2 3 4 None Minimal Moderate Severe 1. Food cravings carbs/salty/sweet 1 2 3 4 24. Feeling fearful/afraid for no reason 1 2 3 4 2. Trouble controlling urine/leaking 1 2 3 4 25. Loss of skin tone and/or increased wrinkles 1 2 3 4 3. Lack of energy / endurance 1 2 3 4 26. Weight loss 1 2 3 4 4. Depression 1 2 3 4 27. Weight gain 1 2 3 4 5. Headaches and/or migraines 1 2 3 4 28. Low back and/or joint pain 1 2 3 4 6. Rapid mood changes/mood swings 1 2 3 4 29. Increased hostility/aggression 1 2 3 4 7. Lack of sex drive/libido/sexual desire 1 2 3 4 30. Dry skin 1 2 3 4 8. Water retention 1 2 3 4 31. Brittle nails 1 2 3 4 9. Difficulty falling and staying asleep 1 2 3 4 32. Unable to tolerate cold 1 2 3 4 10. Memory problems/forgetfulness 1 2 3 4 33. Heavy and/or irregular periods 1 2 3 4 11. Acne/oily skin 1 2 3 4 34. Hand tremors 1 2 3 4 12. Increased anxiety 1 2 3 4 35. Nervousness 1 2 3 4 13. Increased irritability and/or anger 1 2 3 4 36. Rapid, pounding and/or irregular heartbeat 1 2 3 4 14. Hair is thinning/hair loss 1 2 3 4 37. Abdominal bloating, indigestion, slow digestion, or constipation 1 2 3 4 15. Increased growth of facial hair 1 2 3 4 38. Puffy face or eyelids in the morning 1 2 3 4 16. Breast tender, sore, and/or swollen 1 2 3 4 39. Morning fatigue 1 2 3 4 17. Vaginal dryness/pain/itching 1 2 3 4 40. Afternoon fatigue 1 2 3 4 18. Hot flashes/night sweats 1 2 3 4 41. Increased allergies, asthma, or arthritis 1 2 3 4 19. Trouble thinking and/or foggy thinking 1 2 3 4 42. I wake up during the night, can t return to sleep 1 2 3 4 20. Decreased motivation 1 2 3 4 43. I wake up during the night, but return to sleep 1 2 3 4 21. Decreased sexual arousal and/or pleasure 1 2 3 4 22. Muscle weakness and/or loss of strength 1 2 3 4 23. Decreased focus and/or attention span 1 2 3 4 Page 7