Your Hormone Advisor Pharmacist Frank

Women's Medical History & Symptoms

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Today's Date First Name Mi Last Name Address City State Zip Phone E-mail Date of Birth Age Height Weight Marital Status
Use Tobacco
Yes
No
If so how many Pks?
Alcohol Consumtion
Yes
No
If so what amount used per week?
Soda or Carbonated Beverages
Yes
No
How many per week? Occupatuion Primary Care Physician Physician' Address Physician City Physician's State & Zip Office Phone Number Physician's Fax Number (needed) OBGYN Physician's Name Physician's Address Physicians City, State, Zip Physian's Phone Number Physicians Fax Number Non Prescription drugs Current Prescriptions Current Diagnosis Current Diagnosis Continued Past Hormones Exercise Times Per Week Number of Pregnancies Number of Children Any Miscarriages
Hysterectomy
Yes
No
Date Ovaries Removed & Date Tubbal Ligation and Date Abalation Yes or No and Date
Family History of Breast Cancer
Yes
No
Date of Last Mamogram Date of Last Pap Date of Last Period How Long in Days
Abnormal Periods
Yes
No
If Abnormal Explain Age of First Period Referred By? Have any Questions about BHRT? Goal for Hormone Therapy
Increased Forgetfulness
None
Mild
Moderate
Severe
Foggy Thinking
None
Mild
Moderate
Severe
Tearful
None
Mild
Moderate
Severe
Sadness-Depression
None
Mild
Moderate
Severe
Mood Swings
None
Mild
Moderate
Severe
Fluid Retention-Bloating
None
Mild
Moderate
Severe
Stress
None
Mild
Moderate
Severe
Anxious
None
Mild
Moderate
Severe
Irritable
None
Mild
Moderate
Severe
Nervous
None
Mild
Moderate
Severe
Decrease Mental Sharpness
None
Mild
Moderate
Severe
Morning Fatigue
None
Mild
Moderate
Severe
Afternoon Fatigue
None
Mild
Moderate
Severe
Evening Fatigue
None
Mild
Moderate
Severe
Difficulty Falling Asleep
None
Mild
Moderate
Severe
Difficulty Staying Asleep
None
Mild
Moderate
Severe
Decreased Stamina
None
Mild
Moderate
Severe
Ringing in Ears
None
Mild
Moderate
Severe
Allergies
None
Mild
Moderate
Severe
Headaches/Migraines
None
Mild
Moderate
Severe
Dizzy Spells
None
Mild
Moderate
Severe
Sugar Cravings /Carb Cravings
None
Mild
Moderate
Severe
Constipation
None
Mild
Moderate
Severe
Goiter
None
Mild
Moderate
Severe
Cold Body Temperature
None
Mild
Moderate
Severe
Hoarseness
None
Mild
Moderate
Severe
Hair Dry or Brittle
None
Mild
Moderate
Severe
Nails Breaking or Brittle
None
Mild
Moderate
Severe
Slow Pulse Rate
None
Mild
Moderate
Severe
Rapid Heartbeat
None
Mild
Moderate
Severe
Heart Fluttering/Palpitations
None
Mild
Moderate
Severe
Incontinence
None
Mild
Moderate
Severe
Hot Flashes
None
Mild
Moderate
Severe
Night Sweats
None
Mild
Moderate
Severe
Infertility Concerns
None
Mild
Moderate
Severe
Acne
None
Mild
Moderate
Severe
Scalp Hair Loss
None
Mild
Moderate
Severe
Weight Gain Hips
None
Mild
Moderate
Severe
Weight Gain Waist
None
Mild
Moderate
Severe
High Cholesterol
None
Mild
Moderate
Severe
Elevate Triglycerides
None
Mild
Moderate
Severe
Decreased Libido
None
Mild
Moderate
Severe
Decreased Muscle Size
None
Mild
Moderate
Severe
Decreased Flexibility
None
Mild
Moderate
Severe
Burned Out Feeling
None
Mild
Moderate
Severe
Sore Muscles
None
Mild
Moderate
Severe
Increased Joint Pain
None
Mild
Moderate
Severe
Neck or Back Pain
None
Mild
Moderate
Severe
Bone Loss
None
Mild
Moderate
Severe
Thinning Skin
None
Mild
Moderate
Severe
Rapid Aging
None
Mild
Moderate
Severe
Aches and Pains
None
Mild
Moderate
Severe
Irritable Bowel Syndrome
None
Mild
Moderate
Severe
Vaginal Dryness
None
Mild
Moderate
Severe
Irregular Periods
None
Mild
Moderate
Severe
Uterine Fibroids
None
Mild
Moderate
Severe
Breast Tenderness
None
Mild
Moderate
Severe
Fibrocystic Breasts
None
Mild
Moderate
Severe
Increased Facial/Body Hair
None
Mild
Moderate
Severe
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