Women’s BHRT Evaluation Form From a clinical management point of view, it is very useful to gain a detailed history of possible hormone deficiencies. All information provided will be kept confidential. After you fill out this evaluation a pharmacy representative with contact you within 72 hours to set up a consultation time with one of our pharmacist consultants at our Taylor Street location. There is an initial consultation fee of $125.00, payable at time of visit. The time allowed for an initial consult is 60 minutes. Follow up consultations will be billed according to time allowed. Please see Office Policies for more details. Complete the below evaluation to get started. General Information First Name: Last Name: Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email: Date of Birth: Home Phone Work Phone Mobile Phone Occupation: Hours Worked: Full-Time Part-Time Retired Marital Status: MarriedSingleDivorcedWidowed How did you hear about Bio-Identical Hormone Replacement? Do you understand what Bio-Identical Hormone Replacement (BHRT) is? What are your goals for (BHRT)? Medical Status Age: Height: Weight: General Health: Excellent Good Fair Poor Current Medical Conditions: Drug Allergies: Environmental/Food Allergies: Current Medications: Current Vitamins/OTC Products: Current Herbs: Have you ever had your cholesterol level checked? YesNo If yes, what was the date? If yes, what was the results? Have you ever had a mammogram? YesNo If yes, what was the date? If yes, what was the results? Have you ever had a bone density scan? YesNo If yes, what was the date? If yes, what was the results? Have you ever had your hormone levels tested? YesNo If yes, what type of test? SalivaBlood If yes, what was the date? Current Physician: Do you have prescription insurance? Insurance Company Insurance ID# Group # BIN# Past Medical Conditions Childhood Diseases Please Check All That Apply to You: Heart Trouble Diabetes Fractures Asthma Chronic Fatigue High Blood Pressure Clotting Defects Arthritis Cancer Stroke Kidney Trouble Colitis Fibromyalgia Varicose Veins Epilepsy Gallbladder Trouble Eating Disorder Chronic Fatigue Habits Dietary Restrictions Do you get routine physical exercise? YesNo If yes, what type? Do you currently use Tobacco products? YesNo If yes, how much? If you previously used Tobacco products, how much did you use to use? Do you currently use Alcohol products? YesNo If yes, how much? If you previously used Alcohol products, how much did you use to use? Do you currently use Caffeine products? YesNo If yes, how much? If you previously used Caffeine products, how much did you use to use? Do you use artificial sweeteners? YesNoThird Choice If yes, how much? What kind? Family History Please list family members and their age which are still living that may have important diseases such as: High Blood Pressure, Heart Disease, Cancer, Diabetes, Osteoporosis, ect. Please list any family members who died of important diseases (see above question) and their age at the time of death Gynecological History Age at first period Date of last period Date of last pelvic exam Results Date of last Pap Smear Results Have you ever had an abnormal pap? Yes No If yes, what was the treatment? Are you sexually active? Yes No Are you trying to get pregnant? Yes No How many days from the start of one period to the start of the next? How many days of flow? Days amount of bleeding? Days amount of cramps? Days amount of Premenstrual Symptons? Any bleeding between periods? Yes No If yes, when? Age at 1st Pregnancy How many full term pregnancies? Any problems? Any interrupted pregnancies (Miscarriages or Abortions)? Have you had a tubal ligation? Yes No If yes, when? Have you had a hysterectomy? Yes No If yes, when? Have your ovaries been removed? Yes No Method of Birth Control Birth Control Pills Partner Vasectomy Hysterectomy Other If other method of birth control, what treatment? Past/Current Hormone Replacement Therapy Please list any hormone replacements you have taken, (Birth Control, Estrogens, Progestins, etc.) List Drug, Date Taken, Problems or Reasons for Stopping Symptoms Please rate your current status for each Symptom. Hot Flashes Absent Mild Moderate Severe Night Sweats Absent Mild Moderate Severe Headaches Absent Mild Moderate Severe Difficulty Falling Asleep Absent Mild Moderate Severe Difficulty Staying Asleep Absent Mild Moderate Severe Breast Tenderness Absent Mild Moderate Severe Irritability Absent Mild Moderate Severe Depression Absent Mild Moderate Severe Weight Gain Absent Mild Moderate Severe Low Libido Absent Mild Moderate Severe Fuzzy Thinking Absent Mild Moderate Severe Bloating Absent Mild Moderate Severe Anxiety Absent Mild Moderate Severe Mood Swings Absent Mild Moderate Severe Vaginal Dryness Absent Mild Moderate Severe Fatigue Absent Mild Moderate Severe Hair Loss Absent Mild Moderate Severe Constipation Absent Mild Moderate Severe Salt Cravings Absent Mild Moderate Severe Sugar Cravings Absent Mild Moderate Severe Acne Absent Mild Moderate Severe Painful Intercourse Absent Mild Moderate Severe Fertility Issues Absent Mild Moderate Severe Joints Ache and Pains Absent Mild Moderate Severe Increased Facial or Body Hair Absent Mild Moderate Severe Dry/Brittle Hair or Nails Absent Mild Moderate Severe Cold Body Temperature Absent Mild Moderate Severe Unusual Sweating Absent Mild Moderate Severe Bulging Eyes Absent Mild Moderate Severe Blood Pressure Problems Absent Mild Moderate Severe Hoarseness Absent Mild Moderate Severe Any additional comments Comments This field is for validation purposes and should be left unchanged.