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 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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