Microsoft word - confidential hormone evaluation form 2006.doc

Confidential Hormone Evaluation Form
Please fill out the information completely, then fax or send to: Hazle Compounding Attn: Lori Ann Gormley, R.Ph., Certified Menopause Educator 7 N. Wyoming Street Hazleton, PA 18201 Fax: 570-454-4532 or 800-400-8764 Our Menopause Educator will then contact you to schedule your hormonal consultation either in person or by phone. Home Phone: ___________________ Work Phone: ____________________Email: _______________________ Doctor’s Name:
Address: Phone:
Allergies: Please check all that apply:
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 (ex:Triaminic
) Sleep aids (ex:Excedrin PM
, Unisom
, Sominex
) Antidiarrheals (ex:Imodium
,PeptoBismol
, Kaopectate
Laxatives/stool softeners (ex:Doxidan
, Correctol
) Diet aids/weight loss products (ex:Dexatrim
) Acid blockers (ex:Tagamet HB
,Pepcid AC
,Zantac 75
) Antihistamine product (ex:Chlor-Trimeton
) Nutritional/Natural Supplements: Please identify and list the products you are using:
Vitamins (ex: multiple or single vitamins such as B complex, E, C, beta carotene) Minerals (ex: calcium, magnesium, chromium, colloidal minerals, various single minerals) Herbs (ex: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc) Enzymes (ex: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc) Nutrition/protein supplements (ex: shark cartilage, protein powders, amino acids, fish oils, etc) Are you currently using any over the counter products for the relief of hormonal
symptoms ( examples: herbs, homeopathic remedies, estrogen and or progesterone
creams)?
Medical Conditions/Diseases Please check all that apply to you.
Heart disease (ex: Congestive Heart Failure) Lung condition (ex: asthma, emphysema, COPD) High cholesterol or lipids (ex: Hyperlipidemia) Do you experience any of the following? Yes No Sometimes
1. indigestion, gas heartburn, cramping _____ _____ _____
2. poor appetite, nausea, heartburn _____ _____ _____
3. constipation or diarrhea _____ _____ _____
4. diet changes for bowel integrity _____ _____ _____
5. crave sweets _____ _____ _____
6. allergies – food or environmental _____ _____ _____
7. muscle/joint cramping or soreness _____ _____ _____
8. eyes sensitive to bright light, stress _____ _____ _____
9. flashes, sparks or floaters in eyes _____ _____ _____
10. headaches _____ _____ _____
11. poor circulation, hands, feet _____ _____ _____
12. toxic metal exposure – work/living _____ _____ _____
13. emotional stress, anxiety, depression _____ _____ _____
14. parasitic or bacterial infections _____ _____ _____
15. special or vegetarian diet _____ _____ ______
16. fatigue _____ _____ _____
Current Prescription Medications:
Medication Name
Strength
Date Started
How often per day
Bone Size: ____________Small ____________Medium ______________Large Bone Type: ____________Androgenic (larger upper body compared to lower body) ____________Estrogenic (Smaller upper body compared to lower body) How many pregnancies have you had? _____________How many children? ________________ Any interrupted pregnancies? ____________No ______________Yes Have you had a hysterectomy? ___________No ______________Yes Date of surgery ____________ Ovaries removed? ____________No __________Yes Have you had a tubal ligation? _______________No _______________Yes Date ________________ 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 the date of last test.
Since you first began having periods, have you ever had what YOU consider to be abnormal cycles? Do you have, or did you ever have Premenstrual Syndrome (PMS)? Hormone Replacement Therapy Patient Information Sheet
Please rate the following symptoms
ABSENT MILD MODERATE SEVERE Fibrocystic Breast ________ ________ ________ ________ Weight Gain ________ ________ ________ ________ Heavy/Irregular menses ________ ________ ________ ________ Hot flashes ________ ________ ________ ________ Dry Skin/Hair ________ ________ ________ ________ Anxiety ________ ________ ________ ________ Depression ________ ________ ________ ________ Night Sweats ________ ________ ________ ________ Vaginal Dryness ________ ________ ________ ________ Headaches ________ ________ ________ ________ Irritability ________ ________ ________ ________ Mood Swings ________ ________ ________ ________ Breast Tenderness ________ ________ _________ ________ Sleep Disturbances/Insomnia ________ ________ _________ ________ Cramps ________ _________ _________ ________ Fluid Retention ________ _________ ________ ________ Breakthrough Bleeding ________ ________ ________ ________ Fatigue ________ ________ ________ ________ Loss of Memory ________ ________ ________ ________ Bladder Symptoms ________ ________ ________ ________ Arthritis ________ ________ ________ ________ Harder to Reach Climax ________ ________ ________ ________ Decreased Sex Drive ________ ________ ________ ________ Hair Loss ________ ________ ________ ________
How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?

Doctor __________ Self ___________ Friend/Family Member ____________ Seminar __________
Books/Article _______________ Another patient ______________ Other _____________
If you were referred to Hazle Compounding, who referred you?
What are your goals with taking BHRT?
Question Documentation Form
Please list any other pertinent information that you feel we should know about. Also, please write down any questions you may have about Prescription Bio-Identical Hormone Replacement Therapy (Rx BHRT), or other medications. Any other questions that come up as you read through the materials you have received can be listed below. Our Certified Menopause Educator will then discuss this information with you. This information is strictly confidential and is in accordance with all HIPPA regulations.

Source: http://www.hazlecompounding.com/images/Hormone%20Eval.pdf