Pcca confidential hormone evaluation - medical history - …

PCCA CONFIDENTIAL HORMONE EVALUATION
MEDICAL HISTORY
Name: __________________________________
Today’s Date:
Home Phone:______________________________
Birthdate:
Age: _____
Cell Phone: ______________________________
Address: ___________________________________________________________________
Work Phone: ______________________________
City: _________________________________
E-Mail:_____________________
State: _____
Zip: _________________
Occupation: _________
Height: _________
Weight: _________
Doctor’s Name:
Address:
Allergies: Please check all that apply.
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food allergies ___ no known allergies other: _____________________ Please describe the allergic reaction you experienced and when it occurred? Over-the-counter (OTC) issues:
Please check all products that you use occasionally or regularly. Check all that apply.
___ Combination product (cough+cold reliever)(example: Triaminic DM®) ___ Sleep aids (exmples: Excedrin PC®, Unisom®, Sominex®, Nytol®) ___ Antidiarrheals (examples:Imodium®, Pepto Bismol®, Kaopectate®) ___ Laxatives/stool softeners (examples: Doxidan®, Correctol®, etc.) ___ Diet aids/weight loss products (example: Dexatril®) ___ Antacids (examples: Maalox®, Mylanta®) ___ Cough suppressant (example: Robitussin DM®) ___ Acid blockers (examples: Tagamet HB®, Pepcid C®, Zantac 75®) ___ Antihistamine product (example: Chlor-Trimeton®) ___ Decongestant product (example: Sudafed ®) ______________________________________________________ PATIENT NAME:
____________________________
2002 PCCA – Professional Compounding Centers of America. All rights reserved.
Nutritional/Natural Supplements: Please identify and list the products you are using:
vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene) minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals) herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.) enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.)
Medical Conditions/Diseases: Please check all that apply to you.
___
Heart disease (example: Congestive Heart Failure) High cholesterol or lipids (examples: Hyperlipidemia) High blood pressure (example: Hypertension) Lung condition (example: asthma, emphysema, COPD) Other: Please list: ____________________________
Current Prescription Medications:

Medication Name

List Hormones previously taken.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Bone Size
Have you ever used oral contraceptives? If YES, describe any problem(s).
________________________________________________________________________________
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PATIENT NAME:
____________________________
2002 PCCA – Professional Compounding Centers of America. All rights reserved.
How many pregnancies have you had? ____
How many children? ___________________
Yes (Date of Surgery) _________________
Do you have a family history of any of the following?


Have you had any of the following tests performed? Check those that apply and note date of
last test.

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? _____________________________________________________ _____________________________________________________ Do you have, or did you ever have Premenstrual Syndrome (PMS)? If YES, explain symptoms:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PATIENT NAME:
___________________________
2002 PCCA – Professional Compounding Centers of America. All rights reserved. How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?
What are your goals with taking BHRT?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please write down any questions you have about Bio-Identical Hormone Replacement
Therapy.
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What is your greatest need or problem?
________________________________________________________________________________
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Patient Name:
____________________________
2002 PCCA – Professional Compounding Centers of America. All rights reserved.

HORMONE REPLACEMENT THERAPY PATIENT INFORMATION SHEET

Patient Name:
____________________________
2002 PCCA – Professional Compounding Centers of America. All rights reserved.

Source: http://www.grovepharmacy.com/wp-content/uploads/2012/11/bhrt-form.pdf