Hormone Self Assessment Questionnaire 528 E. Spokane Falls Blvd., #110

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Hormone Self Assessment Questionnaire 528 E. Spokane Falls Blvd., #110 Email: chudek@riverpointrx.com Spokane, WA 99202 Website: www.riverpointrx.com Phone: 509-343-6252 or 888-550-1566 Fax: 509-343-6251 or 888-567-5937 Dear Patient, I have designed this questionnaire to learn more about you in order to assist you in achieving your optimum health. I believe that a woman s lifestyle, habits and other characteristics are a vital part of her health assessment and your participation in this process will help me better evaluate your test results, risk factors and preventive needs. This information will be placed in a secure file and will NOT be shared with anyone including your insurance company. If you feel uncomfortable answering any of the questions, please feel free to leave the answer blank. Patient Name: Date of Birth: Today s Date: Address: City: State: ZIP: Phone: (Home) (Work) (Cell) Physicians name: RX Insurance: Insurance Group # ID# BIN # Allergies: Food Seasonal Drugs (please list) Other: Over the Counter Product Use Please check all products that you use whether occasionally or regularly. Aspirin Acetaminophen (ex. Tylenol ) Ibuprofen (ex. Motrin IB ) Naproxen (ex. Aleve ) Ketoprofen (ex. Orudis KT ) Cough Suppressant (ex. Robitussin DM ) Antihistamine Decongestant (ex. Sudafed ) Combination Cough & Cold Products Sleep Aids (ex. Nytol ) Laxatives/stool softeners Diet Aids, Weight Loss products Antacids (ex. Maalox ) Acid Blockers (ex. Tagamet HB, Pepcid AC ) Others: Nutritional Supplements: Please list any vitamins, minerals, herbs, enzymes, nutrition, protein or other supplements that you take on a regular or occasional basis: Current Prescription Medications: Medication Name Strength Date Started How often per day Riverpoint Pharmacy Page 1

List Hormones Previously Taken: Name Strength Date Started Date Stopped Reason Have you ever used oral contraceptives? No Yes Any Problems? No Yes If YES, describe problems: Does you anyone in your family have, or has had, any of the following: Breast Cancer Ovarian Cancer Uterine Cancer Fibrocycstic Breast Heart Disease Osteoporosis Diabetes Medical History General Health: Excellent Good Fair Poor Height: Weight: Please check all that apply: Breast Cancer Ovarian Cancer Uterine Cancer Heart Disease Diabetes High Blood Pressure Osteoporosis Stroke Endometriosis Fibroids Blood Clots Impaired Liver Function Fibrocystic Breast Other Reproductive Health Menstrual Periods: None Regular Irregular (describe) Age of first period Age of last period Have you ever been pregnant? No Yes # of children Have you ever had infertility treatments? No Yes Describe Any interrupted prenancies? No Yes Describe Have you had a hysterectomy? No Yes Date Reason: Ovaries Removed? No Yes Date Have you had a tubal ligation? No Yes Date Have you had a D & C? No Yes Date Have you had an ablation? No Yes Date Date of most recent Pap Test: Results: Date of last cholesterol check: Results: Have you ever had a mammogram: Date Results: Have you ever had a bone density scan: Date Results: Riverpoint Pharmacy page 2

Lifestyle Information Form Physical Activity 1. In the past year, how often have you engaged in physical activity? Regularly (3-4 times/week) Semi-regularly (1-2 times/week) Sporadic (1-2 times/month) None 2. What types of physical activity do you consider fun? 3. What are your personal barriers to exercise? 4. What physical activity have you been successful with in the past (liked and participated in regularly)? 5. How do you think your weight affects your daily activities? Support 1. Do you feel any family, friends, or co-workers have negative feelings toward your efforts at physical activity? 2. Is your significant other or a close friend involved in any regular physical activity? Occupation/Leisure 1. What is your present occupation? 2. Does your occupation require much activity? 3. What are your leisure activities? Stressors 1. What types of things make you feel stressed? 2. How do you deal with stress normally? 3. Do you feel that exercise would be useful to help manage stress? Expectations Specifically what you would like to accomplish through your fitness program during the next: One month 4 months 1 year Riverpoint Pharmacy Page 3

To what degree do you experience the following? Difficulty Concentrating/Loss of Memory Can't Sleep Depressed or Unhappy Anxious Headaches Moodiness/Emotional Swings Painful or Swollen Breasts Weight Gain/Bloating PMS Night Sweats Difficulty Remembering Things Hot Flashes Vaginal Dryness Dry Hair/Skin Urine Leakage (Incontinence) Frequent Urinary Tract Infections Inability to Reach Orgasm Painful Intercourse Lack of Sexual Desire Fatigue/Loss of Energy What are your goals for Bio-Identical HRT? Waiver I herby release Riverpoint Pharmacy and all of its employees and pharmacists from any and all liability whatsoever associated or connected with my Natural (Bio-Identical) Hormone Replacement consultations and/or use of Natural (Bio-Identical) Hormone Replacement. I hereby state that I am an adult and that I am aware of the potential side effects associated with Natural (Bio-Identical) Hormone Replacement. I hereby agree to answer truthfully all of the medical questions on my questionnaire. I understand that no doctor, nurse, pharmacist, or administrative personnel can guarantee that Natural (Bio-Identical) Hormone Replacement will provide the results I seek. I hereby release Riverpoint Pharmacy and all of its employees from any and all liability whatsoever associated with any adverse effects I may suffer from my use of Natural (Bio-Identical) Hormone Replacement. I am participating in this program at my own choice, and I assume all responsibility for my use of Natural (Bio-Identical) Hormone Replacement. I fully understand that it is my responsibility to have an annual physical examination, including any suggested laboratory tests to ensure that I have no medical conditions that might make Natural (Bio-Identical) Hormone Replacement inappropriate for my condition. Signed Date Riverpoint Pharmacy Page 4

Billing Information Your credit card will be billed for the cost of the prescription and if shipped by mail the shipping will be at no extra charge. Your order will be shipped by USPO or Federal Express unless otherwise specified. We accept Master Card, Visa, American Express, Discover, Checks, money orders and cash. Riverpoint Pharmacy honors many prescription insurance plans. Please send a copy of the front and back of your insurance plan membership card or call this information into us at (509) 343-6252 or (888) 550-1566. Your name as it appears on your credit card: Credit Card Number: Expiration Date (mm/yy): Chose your shipping method: USPO No Charge (generally delivered the next day in the Spokane area) Priority Mail..$4.00 2 nd Day $10.00 Overnight $20.00 Overnight on ice $35.00 Please initial if you agree to have you package left at your home without a signature. Riverpoint Pharmacy assumes no liability for lost, stolen or damaged packages. Please let us know how you heard about Bio-Identical Hormone Replacement Therapy: Advertisement: Newspaper: Books: Magazine: Healthcare Provider: Other: All Information can be faxed, mailed, or scanned and emailed to Riverpoint Pharmacy at: Fax: (888) 567-5937 Email: chudek@riverpointrx.com Address: 528 E. Spokane Falls Blvd., #110 Spokane, WA 99202 If you have any questions call us between 8:00am and 5:00pm PacificTime at: (509) 343-6252 or (888) 550-1566. Riverpoint Pharmacy Page 5

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