Pcca confidentail hormone evaluation

PCCA CONFIDENTIAL HORMONE EVALUATION
MEDICAL HISTORY
Name: _________________________________ DOB:_________________ Age:______ Address: ________________________________________________________________ City_________________________________ State: _______________ Zip:___________ Phone: ______________ Cell: __________________ Email: ______________________ Gender: Male Female Do you use tobacco? Yes No ____________________________________ Do you use alcohol? Yes No ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies: Please check all that apply: ___ Penicillin ___ Food Allergies ___ No known Allergies Other: __________________________________________________________________ Please describe the allergic reaction you experienced when it occurred: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Over the counter (OTC) issues: Please check all products that you use occasionally or regularly: Check all that apply. ___ Pain Reliever ___ Combination products (cough/cold reliever) ex: Traminic DM ___ Sleep aids (ex: Excedrin PC, Unisom, Sominex, Nytol) ___ Antidirrheals (ex: Imodium, Pepto Bismol, Kaopectate) ___ Laxatives/ Stool softners (Doxiden, Correctol, etc…) ___ Diet aids/weight loss products (ex: Dexatrim) ___ Acid blocker (ex: Tagamet HB, Pepcid C, Zantac 75) ___ Anisthistamine product (ex: Chlor-Trimeton ___ Other (please list)________________________________ ___ Decongestant product (ex: Sudafed) ______________________________________________ How many pregnancies have you had? ________ How may children? _______________ (Please circle) Any interrupted pregnancies? Do you have a family history of any of the following? Uterine Cancer _______________ Family member(s)___________________________ Ovarian Cancer _______________ Family member(s)___________________________ Fibercystic breast _______________ Family member(s)___________________________ Breast Cancer ________________ Family member(s)__________________________ Heart Disease ________________ Family member(s)___________________________ Osteoporosis ________________ Family member(s)___________________________ Have you had any of the following tests performed? Circle those that apply & note date of last test. Mammography Date: _____________________________________ Date: _____________________________________ Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles: (Please circle) If YES, please explain (such as age when this occurred, symptoms…) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ When was your last menstrual cycle? _________________________________________ How many days did it last? _________________________________________________ Do you have, or did you ever have Premenstrual Syndrome (PMS)? Yes If YES, explain symptoms:__________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ Patent Name: ___________________________________________________________ Nutritional Supplements: Please identify and list the products you are using: (check all that apply) ___ Vitamins (ex: multiple/single vitamins such as B complex, E, C, beta carotene) ___ Minerals (ex: calcium, magnesium, chromium, colloidal minerals, various single minerals) ___ Herbs (ex: ginsing, gingko biloba, Echinacea, other herbal medicine teas, lincures, remedies, etc…) ___ Enzymes (ex: digestive formulas, papya, bromelain, CoEnzyme Q10, etc…) ___ Nutrition/Protein Supplements (ex: shark cartilage, protein powders, amino acids, fish oils, etc…) ___ Others (glucosamine, etc…) Medical Conditions/Diseases; Please check all that apply to you. ___ Heart Diseases (ex: Congestive Heart Failure) ___ High cholesterol or lipids (ex: Hyperlipidemia) ___ High blood pressure (ex: Hypertension) ___ Lung Condition (ex: asthma, emphysema, COPD) ___ Other: Please list:______________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Current Prescription Medications: Medication Name ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List Hormones previously taken ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Bone size: Have you ever used oral contraceptives? If YES, describe any problem(s) _____________________________________________ _______________________________________________________________________________________________________________________________________________ Pateint Name: ____________________________________________________________ How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy? (Please circle) Doctor What are your goals with taking BHRT? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please write down any questions you have about Bio-Identical Hormone Replacement Therapy ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.sugarlandmedicalandaestheticspa.com/forms/PCCA%20CONFIDENTAIL%20FEMALE%20HORMONE%20EVALUATION.pdf

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Department of Radiology & Imaging Services 1105 Central Expressway North• Allen, Texas 75013 Phone (972) 747-6141 • Fax (972) 747-6147 ICD-9 Code  Send CD  Call Report  Call Patient Patient Phone: NUCLEAR MEDICINE  XR IVP  with tomos  without tomos Gastric Emptying Hepatobiliary/HIDA Scan FLUOROSCOPY CONTRAST/ LABS   Dobutamine

Microsoft word - qch valentines 2014 menu - with price.docx

Valentine’s Day Supper Menu, 2014 - £49.99 Tonight we celebrate the legend of Aphrodite, the Greek Goddess of Love and Beauty, the mother of Eros, and from whom the word Aphrodisiac was born. Every culture has it’s own unique twist on St. Valentine’s Day and true to our culture at the Olive Tree we have created our own bespoke menu, with 6 dishes each designed with their own ap

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