Microsoft word - rtf2.rtf

Please complete all pages and fax to: 626-791-5010
Washington Pharmacy
Medical History
Today’s Date:
Name: __________________________________ Birthdate:
Age: _____
Address: ________________________________________________________________________
City: _________________________________
State: _____
Zip: _________________
E-Mail Address:
Height: _________
Weight: _________
Doctor’s Name:
Address:
Allergies: Please check all that apply.
___
food allergies ___ no known allergies other: _____________________ 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)(example: Triaminic DM®) ___ Sleep aids (exmples: Excedrin PC®, Unisom®, Sominex®, Nytol®) ___ Antidiarrheals (examples:Imodium®, Pepto Bismol®, Kaopectate®) ___ Laxatives/stool softeners (examples: Doxidan®, Correctol®, etc.) ___ Diet aids/weight loss products (example: Dexatril®) ___ Antacids (examples: Maalox®, Mylanta®) ___ Cough suppressant (example: Robitussin DM®) ___ Acid blockers (examples: Tagamet HB®, Pepcid C®, Zantac 75®) ___ Antihistamine product (example: Chlor-Trimeton®) ___ Decongestant product (example: Sudafed ®) ______________________________________________________ PATIENT NAME: ____________________________
Nutritional/Natural Supplements: Please identify and list the products you are using:
vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene) minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals) herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.) enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.) others (glucosamine, etc.) Medical Conditions/Diseases: Please check all that apply to you.
Heart disease (example: Congestive Heart Failure) High cholesterol or lipids (examples: Hyperlipidemia) High blood pressure (example: Hypertension) Lung condition (example: asthma, emphysema, COPD) Other: Please list: ____________________________ Current Prescription Medications:
List Hormones previously taken.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
If YES, describe any problem(s). ________________________________________________________________________________________________________________________________________________________________ PATIENT NAME: ____________________________
WashingtonPharmacy
Please complete all pages and fax to: 626-791-5010
How many pregnancies have you had? ____
How many children? ___________________
Yes (Date of Surgery) _________________ 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 date of
last test.
Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles? If YES, please explain (such as age when this occurred, symptoms….): ___________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________ _____________________________________________________ Do you have, or did you ever have Premenstrual Syndrome (PMS)? If YES, explain symptoms:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PATIENT NAME: ___________________________
WashingtonPharmacy
Please complete all pages and fax to: 626-791-5010
How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?
What are your goals with taking BHRT?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please write down any questions you have about Bio-Identical Hormone Replacement
Therapy.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Patient Name:
____________________________
WashingtonPharmacy
Please complete all pages and fax to: 626-791-5010
HORMONE REPLACEMENT THERAPY PATIENT INFORMATION SHEET
Patient Name:
____________________________
WashingtonPharmacy
Please complete all pages and fax to: 626-791-5010

Source: http://washingtonrx.ucoz.net/ConfPtinfo.pdf