Microsoft word - confidential hormone evaluation.doc

d ess:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Alle Please describe the allergic reaction you experienced and when it occurred? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Ove Please check all products that you use occasionally or regularly. Check all that apply. Combination product (cough+cold reliever)(e.g.: Triaminic DM®) Sleep aids (e.g.: Excedrin PC®, Unisom®, Sominex®, Nytol®) Antidiarrheals (e.g.:Imodium®, Pepto Bismol®, Kaopectate®) Laxatives/stool softeners (e.g.: Doxidan®, Correctol®, etc.) Diet aids/weight loss products (e.g.: Dexatril®) Cough suppressant (e.g.: Robitussin DM®) Acid blockers (e.g.: Tagamet HB®, Pepcid C®, Zantac 75®) Antihistamine product (e.g: Chlor-Trimeton®) Other (please list)___________________________________ ______ Decongestant product (e.g: Sudafed ®) ______________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 t : Please identify and list the products you are using: vitamins (e.g.: multiple or single vitamins such as B complex, E, C, beta carotene) minerals (e.g: calcium, magnesium, chromium, colloidal minerals, various single minerals) herbs (e.g: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.) enzymes (e.g: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) nutrition/protein supplements (e.g: shark cartilage, protein powers, amino acids, fish oils, etc.) others (glucosamine, etc.) None a es: Please check all that apply to you. Heart disease (e.g.: Congestive Heart Failure) High cholesterol or lipids (e.g.: Hyperlipidemia) High blood pressure (e.g.: Hypertension) Lung condition (e.g.: asthma, emphysema, COPD) Other: Please list: _______________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Li ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Bone Size: Have you ever used oral contraceptives? No Yes Any problems? No Yes If YES, describe any problem(s). ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 - Family member(s) ___________________________________ - Family member(s) ___________________________________ Fibrocystic breast - Family member(s) ___________________________________ Breast Cancer - Family member(s) ___________________________________ - Family member(s) ___________________________________ - Family member(s) ___________________________________ - Family member(s) ___________________________________ Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles? If YES, please explain (such as age when this occurred, symptoms….) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ When was your last period? _______________________________________________ How many days did it last? _______________________________________________ Do you have, or did you ever have Premenstrual Syndrome (PMS)? No Yes If YES, explain symptoms and rate severity: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Ple ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Ple ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809

Source: http://custommedicine.com/CONFIDENTIAL%20HORMONE%20EVALUATION.pdf