Collierdrug.com

GENDER: M F
DO YOU USE TOBACCO? YES NO
DO YOU USE ALCOHOL? YES NO
DO YOU USE CAFFEINE? YES NO
DOCTOR’S NAME
ALLERGIES (PLEASE CHECK ALL THAT APPLY TO YOU.)
[ ] Penicillin
[ ] Aspirin
[ ] No Known Allergies
[ ] Other:
[ ] Codeine
[ ] Food Allergies
[ ] Pet Allergies
[ ] Sulfa Drug
[ ] Dye Allergies
[ ] Seasonal (pollen) Allergies
[ ] Morphine
[ ] Nitrate Allergy
PLEASE DESCRIBE THE REACTION YOU EXPERIENCED AND WHEN IN OCCURRED:
Bio-Identical Hormone Evaluation form cont.
OVER-THE-COUNTER ISSUES (PLEASE CHECK ALL THAT APPLY TO YOU.)
[ ] Pain reliever
[ ] Combination (cough + cold releiver/ex: Triminc DM®)
[ ] Aspirin
[ ] Sleep aids (ex: Exedrin PM®, Unisom, Sominex®, Nytol®)
[ ] Acetaminophen (ex: Tylenol®)
[ ] Antidiarrheals (ex: Imodium®, Pepto Bismol®, Kaopectate®)
[ ] Ibuprofen (ex: Motrin IB®)
[ ] Laxatives/stool softeners (ex: Doxidan®, Correctol®)
[ ] Naxproxen (ex: Aleve®)
[ ] Diet aids/weight loss products (ex: Dexatril®)
[ ] Ketoprofen (ex: OrudisKT®)
[ ] Antacids (ex: Maalox®, Mylanta®)
[ ] Cough suppressant (ex: Robitussin DM®)
[ ] Acid blockers (ex: Tagamet HB®, Pepcid C®, Zantac 75®)
[ ] Antihistamine (ex: Chlor-Trimeton®)
[ ] Others:
[ ] Decongestant (ex: Sudafed®)
MEDICAL CONDITIONS/DISEASES (PLEASE CHECK ALL THAT APPLY TO YOU.)
[ ] Heart disease (ex: Congestive Heart Failure)
[ ] Diabetes
[ ] High cholesterol or lipids (ex: Hyperlipidemia)
[ ] Arthritis or joint problems
[ ] High blood pressure (ex: Hypertension)
[ ] Depression
[ ] Cancer
[ ] Epilepsy
[ ] Ulcers (stomach, esophagus)
[ ] Headache/migraines
[ ] Thyroid disease
[ ] Eye disease (ex: Glaucoma, etc.)
[ ] Hormonal related items
[ ] Others:
[ ] Lung conditions (ex: asthma, emphysema, COPD)
[ ] Blood clotting problems
CURRENT PRESCRIPTION MEDICATIONS:
LIST HORMONES PREVIOUSLY TAKEN:
Bio-Identical Hormone Evaluation form cont.
HAVE YOU EVER USED ORAL CONTRACEPTIVES? YES NO ANY PROBLEMS? YES NO
HOW MANY PREGNANCIES HAVE YOU HAD? HOW MANY CHILDREN? ANY INTERRUPTED PREGNANCIES? YES NO
HAVE YOU HAD A HYSTERECTOMY? YES NO / DATE OF SURGERY:
HAVE YOU HAD YOUR OVARIES REMOVED? YES NO
HAVE YOU HAD TUBAL LITIGATION? YES NO / DATE OF SURGERY:
DO YOU HAVE A FAMILY HISTORY OF THE FOLLOWING:
[ ] Uterine cancer / Family member:
[ ] Breast cancer / Family member:
[ ] Ovarian cancer / Family member:
[ ] Heart disease / Family member:
[ ] Fibrocystic breast / Family member:
[ ] Osteoporosis / Family member:
HAVE YOU HAD EITHER OF THE FOLLOWING TEST PERFORMED:
MAMMOGRAPHY? YES NO / DATE:
PAP SMEAR? YES NO / DATE:
SINCE YOU FIRST BEGAN HAVING PERIODS, HAVE YOU EVER HAD WHAT YOU WOULD CONSIDER TO BE ABNORMAL CYCLES? YES NO
IF YES, PLEASE EXPLAIN (AGE, SYMPTOMS, DATES, ETC.) DO YOU, OR DID YOU EVER, HAVE PREMENSTRUAL SYNDROME (PMS)? YES NO
IF YES, PLEASE EXPLAIN (AGE, SYMPTOMS, DATES, ETC.) Bio-Identical Hormone Evaluation form cont.
PATIENT INFORMATION SHEET
MODERATE
Fibrocystic breastWeight gainHeavy / irregular mensusHot flashesDry skin / hairAnxietyDepressionNight sweatsVaginal drynessHeadachesIrritabilityMood swingsBreast tendernessSleep disturbances / insomniaCrampsFluid retentionBreakthrough bleedingFatigueLoss of memoryBladder symptomsArthritisHarder to reach climaxDecreased sex driveHair lossFacial hair WHAT ARE YOUR GOALS
PLEASE WRITE ANY QUESTIONS
WITH TAKING BHRT?
YOU MAY HAVE:

Source: http://collierdrug.com/customer_media/online_forms/cds_bhrt_evalform.pdf