Venushealth.ca

We collect the attached information in order to help identify possible hormone deficiencies in your system. All of the symptoms/information that we ask about have a connection to hormones. We understand that some of the questions we ask are personal and sensitive. We can best help you by receiving complete and accurate information. Together, we will develop a treatment plan with the goals of alleviating your symptoms, contributing to your overall health and bringing quality back to your life. Once you have completed the forms, please email them to Venus Health Inc. Assessment forms are also Please write your name at the top of each page of the attached assessment so all of your information is kept We ask you to provide the information on the following face page so the pharmacy can process your • Extended health plan insurance information • Personal Health Number (from your Care Card) Once we receive your completed assessment, we wil review it and contact you at the number you provide for further consultation and treatment options. We look forward to partnering with you in your health care. Thank Venus Health Inc. .hormonal balance, with nature Client Assessment
Today’s Date: __________________
Name: ______________________________________________________________________________ Address: _____________________________________________________________________________ Phone: __________________________ Client Email Address: __________________________________ Birthdate (year/month/day) ____/_____/____ Height: __________ Provincial Health Number: _________________________ Name of Extended Health Insurance Provider: _______________________________________________ ID # (on extended health card): _________________ Group # (on extended health card): ____________ On the extended health plan, are you (check one)? □ Primary Card Holder □ Spouse OR □ Dependant
Doctor’s Name: _________________________ Doctor’s Address: _______________________________ Doctor’s Phone Number: ____________________
Current Menstrual Status:
First day of last menses (year/month/day) ____/_____/____ Cycle length, e.g., 28 days ______ □ Regular Cycles □ Irregular Cycles □ No menstrual cycles Hysterectomy: □ Yes □ No If yes, year of surgery: ________ Waist measurement: ____________ Hip measurement: __________
Current & Previous Use of Hormones (list hormones used in the past 6 months)
Hormone Therapies
□ Estrogen, e.g., Estraderm, Ogen
□ Progesterone, e.g., Prometrium
□ Testosterone, e.g., Climacteron
□ Other Hormone, e.g., Provera, MPA, Bi-Est, DHEA, Sompatropin: _____________________________
Brand Used: ________________________ Delivery, e.g., oral, cream, patch ______________________ Dose in mg: ______ Last date & hour used: ___________ Number of times/day: ____ # Days/month Length of time used, e.g., 2 years ___________________ Venus Health Inc. .hormonal balance, with nature Client Name: ___________________________

SYMPTOMS
Please indicate your rating for each symptom below using the following rating system: 0 means (none), 1 is
(mild), 2 is (moderate), 3 is (severe). For example if you have moderate allergies you would indicate this by
writing 2 next to ‘Allergies’. If you are not sure, please leave blank. Venus Health Inc. .hormonal balance, with nature Client Name: ___________________________

Allergies: Please check all that apply.
____________________________________________ ____________________________________________ Please describe the al ergic reaction you experienced and when it occurred: ___________________________________________________________________________________________ ___________________________________________________________________________________________
Non-prescription drug use:
Please check all products that you use occasionally or regularly. ___________________________________________________________________________________________ ___________________________________________________________________________________________
Current Prescription Medications:
Medication name, dosage, date started, and how often per day: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
List oral contraceptives previously taken.
Describe any problems associated with taking these. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Venus Health Inc. .hormonal balance, with nature Client Name: ___________________________

Nutritional/Natural Supplements:
Please check al products that you use occasionally or regularly, note the product name and daily □ Vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene) Product name:________________________ Daily dosage: _____________ □ Minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals) Product name:________________________ Daily dosage: _____________ □ Herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, □ Enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) Product name:________________________ Daily dosage: _____________ □ Nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.) □ Others (glucosamine, adrenal supplement, etc.) Venus Health Inc. .hormonal balance, with nature Client Name: ___________________________

Medical Conditions/Diseases: Please check all that apply to you.

□ Heart Disease
□ Diabetes □ or High Blood Sugar
□ Please list any other health concerns: _________________________________________________________________________________
Do you have a family history of any of the fol owing? Check those that apply, identify family member,
e.g., mother, sister, father and whether it is a maternal or paternal relative. Family Member
_________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Venus Health Inc. .hormonal balance, with nature Client Name: ___________________________
Body Type: (e.g., thin, tal , smal breasts, narrow hips, wide hips, etc.) _________________________________________________________________________________ _________________________________________________________________________________ Have you had any interrupted pregnancies? Since you first began having periods, have you ever had what you would consider to be abnormal If yes, please explain (such as age when this occurred, last date this occurred, and symptoms):___________________________________________________________________________ ______________________________________________________________________________ _________________________________________________________________________________ Do you have, or did you ever have Premenstrual Syndrome (PMS)? _____________________________________________________________________________________ _____________________________________________________________________________
Have you had either of the fol owing tests performed?
Check those that apply and note date of the last test.
Venus Health Inc. .hormonal balance, with nature Client Name: ___________________________

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy (BHRT)?
What are your goals with taking BHRT?
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Please write down any questions you have about Bio-Identical Hormone Replacement Therapy
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Venus Health Inc. .hormonal balance, with nature

Source: http://venushealth.ca/Client%20forms.pdf