Welcome to Martin's Wellness and Compounding

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Confidential Hormone Evaluation

  • No Yes
    No Yes
    No Yes
    No Yes
    Penicillin Morphine Dye allergies Pet allergies Codeine Aspirin Nitrate allergy Sulfa drugs Food allergies Seasonal (pollen) allergies No known allergies
    Full time Part time
    Pain Reliever Combination products (cough & cold) Aspirin 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) Cough suppressants Acid blockers (Pepcid, Zantac, Prilosec) Antihistamines (Benadryl) Decongestants (Sudafed)
    Heart Disease (Congestive Heart Failure) Blotting Clotting Problems High Cholesterol or Lipids Diabetes High Blood Pressure Arthritis or Joint Problems Cancer Depression Ulcers Epilepsy Thyroid Disease Headaches/Migraines Lung Conditions (asthma, emphysema, COPD) Eye Disease (glaucoma, etc)
    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)

    Current Prescription Medications

    Hormones Previously Taken

    Please list, including birth control pills and OTC hormonal products

  • No Yes
    No Yes
    No Yes

    Menstrual History

    Uterine Cancer
    Ovarian Cancer
    Fibrocystic Breast
    Breast Cancer
    Heart Disease
    Osteoporosis
    Mammography
    PAP Smear
    Thyroid
    Cortisol
    Bone Density Scan
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
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    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe
    Absent Mild Moderate Severe

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