ALLERGIES: PLEASE CHECK ALL THAT APPLY

Seasonal (pollen) allergies

Please describe the allergic reaction you experienced and when it occurred

Describe your stress level and indicate if it’s temporary stress or chronic stress:

PLEASE CHECK ALL PRODUCTS THAT YOU USE REGULARLY OR OCCASIONALLY. CHECK ALL THAT APPLY

Combination products (cough & cold)

Sleep aids (Tylenol PM, Unisom, Nytol)

Acetaminophen (Tylenol)

Anti-diarrheal’s (Imodium, Pepto-Bismol)

Ibuprofen (Motrin, Advil)

Laxatives/Stool Softeners (Correctal, DSS)

Naproxen (Aleve products)

Diet aids/Weight loss products

Ketoprofen (Orudis KT)

Antacids (Maalox, Mylanta)

Acid blockers (Pepcid, Zantac, Prilosec)

Antihistamines (Benadryl)

Decongestants (Sudafed)

PLEASE CHECK ALL THAT APPLY TO YOU

Heart Disease (Congestive Heart Failure)

Blotting Clotting Problems

High Cholesterol or Lipids

Arthritis or Joint Problems

Lung Conditions (asthma, emphysema, COPD)

Eye Disease (glaucoma, etc)

PLEASE CHECK ALL PRODUCTS THAT YOU USE REGULARLY OR OCCASIONALLY.

Vitamins (multiple or singe vitamins such as B complex, E, C, Beta carotene)

Minerals (Calcium, magnesium, chromium)

Herbs (Ginseng, Ginkgo Biloba, Echinacea, herbal medicinal teas)

Enzymes (Digestive formulas, papaya, Co-enzyme Q10)

Nutrition/Protein supplements (Shark cartilage, protein powder, amino acids, omegas)

Other: Please list by name and strength

Current Prescription Medications

Medication 1 Strength

Medication 1 Date Started

Medication 2 Strength

Medication 2 Date Started

Medication 3 Strength

Medication 3 Date Started

Medication 4 Strength

Medication 4 Date Started

Hormones Previously Taken

Please list, including birth control pills and OTC hormonal products

Hormone 1 Date Started

Hormone 1 Date Stopped

Hormone 1 Stopping Reason

Hormone 2 Date Started

Hormone 2 Date Stopped

Hormone 2 Stopping Reason

Hormone 3 Date Started

Hormone 3 Date Stopped

Hormone 3 Stopping Reason

Hormone 4 Date Started

Hormone 4 Date Stopped

Hormone 4 Stopping Reason

How many pregnancies have you had?

HAVE YOU HAD A HYSTERECTOMY?

HAVE YOU HAD A TUBAL LIGATION?

Menstrual History

Describe your periods: (Are they regular? How many days from the start of one period to the start of the next one? Number days of flow? Describe your flow. Do you have any bleeding between periods? Do you have clots? Do you experience PMS symptoms? When d

Do you have a family history of any of the following?

HAVE YOU HAD ANY OF THE FOLLOWING TESTS PERFORMED?

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?

What are your goals with taking BHRT?

What questions do you have about Bio-Identical Hormone Replacement Therapy?

BIO-IDENTICAL HORMONE REPLACEMENT THERAPY SYMPTOM INFORMATION SHEET ANXIETY

Supplements

Testing

Vaccines

Request a consult