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Patient Information:
* Full Name:
* Street Address:
* City:
* State:
* Zip Code:
* Home Phone:
* Work Phone:
* E-mail:
* Social Security Number:
* Date of Birth (mm/dd/yy):
Gender: Male Female
Height:
Weight:
 
* Method of Payment:
Visa
Mastercard
Discover
Check
Other: (Please Specify Below)
 
(If using Credit Card, please answer questions below.)
Credit Card Holder:
Credit Card # (if using):
Expiration Date (mm/yy):
 
Lifestyle Information:
* Do you use tobacco (smoke, chew, dip)? Yes
No		 If yes, how often and how much?
* Do you use alcohol (beer, wine, hard liquor)? Yes
No 		If yes, how often and how much?
* Do you use caffeine (cola drinks, tea, coffee)? Yes
No		 If yes, how often and how much?
 
* Impairments: (check if you have any of the following): Physical Visual Hearing None
* Exercise: Do you exercise regularly? Yes
No 		If yes, describe what you do and how often:
* Stress Management: Do you practice any stress management techniques? Yes
No 		If yes, describe what you do and how often:
 
* Diet: Describe your typical daily food intake:
First Meal:   Third Meal:
Second Meal:   Any Snacks / Other:
 
Doctor Information:
* Are you currently under the care of a physician?      Yes No
If yes, please list each doctor from whom you seek care, including address and phone number, if known:
Doctor #1:  
Name:
Address:
Phone:
   
Doctor #2:  
Name:
Address:
Phone:
 
Doctor #3:  
Name:
Address:
Phone:
   
Doctor #4:  
Name:
Address:
Phone:
 
Allergies:
* Please check all that apply:   Check this box if none of these apply to you.
Penicillin   Morphine   Aspirin
Pet Allergies   Codeine   Sulfa Drug
Nitrate Allergy   Seasonal Allergies (pollen)   Other:
Food Allergies   Dye Allergies  
 
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):   Check this box if none of these apply to you.
Pain reliever
Aspirin
Acetaminophen (ex: Tylenol®)
Ibuprofen (ex: Motrin IB®)
Naproxen (ex: Aleve®)
Ketoprofen (ex: Orudis KT®)
Cough suppressant (ex: Robitussin DM®)
Antacids (ex: Maalox®, Mylanta®)
Decongestant (ex: Sudafed®)
 
Combination (cough-cold reliever) (ex: Triaminic DM®)
Antihistamine (ex: Chlor-Trimeton®)
Sleep aids (ex: Excedrin PM®, Unisom®, Sominex®, Nytol®)
Antidiarrheals (ex: Imodium®, Pepto Bismol®, Kaopectate®)
Laxatives / stool softeners (ex: Doxidan®, Correctol®)
Diet aids / weight loss products (ex: Dexatrim®)
Acid blockers (ex: Tagamet HB®, Pepcid AC®, Zantac 75®)
Other (please list):
 
* Nutritional / Natural Supplements: Please identify and list the products you are using:
Vitamins (ex: multiple or single vitamins such as B complex, E, C, beta carotene)
Minerals (ex: calcium, magnesium, chromium, colloidal minerals, various single minerals)
Herbs (ex: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.)
Enzymes (ex: digestive formulas, papaya, bromelain, CoEnzymeQ10, etc.)
Nutrition / protein supplements (ex: shark cartilage, protein powders, amino acids, fish oils, etc.)
Others (ex: glucosamine, etc.)
 
Medical Conditions / Diseases:
* Please check all that apply to you:   Check this box if none of these apply to you.
Heart disease (ex: Congestive Heart Failure)
High cholesterol or lipids (ex: Hyperlipidemia)
High blood pressure (ex: Hypertension)
Cancer
Ulcers (ex: stomach, esophagus)
Thyroid disease
Hormonal Related Issues
Blood Clotting Problems
 
Lung condition (ex: asthma, emphysema, COPD)
Diabetes
Arthritis or joint problems
Depression
Epilepsy
Headaches / migraines
Eye Disease (ex: glaucoma, etc.)
Other (please list):
Prescription Medications:
* Please list all prescription medications you are currently using. Be sure to include any mail order or physician samples.
 
  Medication Name: Dose: # of times / day? # of times / week? Doctor:
1.
2.
3.
4.
5.
6.
 

Tests:

* 1. Have you ever had any of the following tests performed? Check those that apply and note date of last test.
Mammography Yes No Date of Test:
PAP Smear Yes No Date of Test:
Pelvic exam Yes No Date of Test:

* 2. Have you ever had an abnormal PAP? Yes No
   If Yes, what treatment was done?
* 3. When did you have your cholesterol checked? Results:

* 4. Do you have any lab volumes you can provide from your last physical with your doctor? Yes No
* 5. Have you ever had a bone density scan? Yes No
   If yes, when? Results:

Menstrual Cycle:
* 1. Since you first began having periods, have you ever had what you would consider to be abnormal cycles?
Yes No            Date of Cycle:
  If Yes, please explain ( such as age, when thisoccurred, symptoms, etc.)
* 2. When was your last period? How many days did it last?:

* 3. How many days from the start of one period to another?

* 4. How many days of bleeding?
* 5. Do you have, or did you ever have Premenstrual Syndrome (PMS)
Yes No 		If yes, please describe symptoms:
When do they start? When do they end?
* 6. Do you experience cramping?
Yes No		 If yes, please describe:
* 7. Have you experienced recent changes in your normal cycle?
Yes No		 If yes, please describe
* 8. Do you experience any bleeding between periods? Yes No
* 9. Do you experience any:
Pelvic Pain?
 Yes No
If yes, please describe
Pelvic Pressure?
 Yes No
If yes, please describe
Fullness? Yes No
If yes, please describe

* 10. Do you experience any unusual vaginal itching? Yes No

Family History:
* 1. Please list family members – and their age – who have had serious discasos such as diabetes, heart disease, cancer, osteoporosis, etc.     
Disease: Relation: Age:
Disease: Relation: Age:
Disease: Relation: Age:
Disease: Relation: Age:

* 2. Please list any family members who have died from serious diseases. 
Disease: Relation: Age:
Disease: Relation: Age:
Disease: Relation: Age:
Disease: Relation: Age:

* 3. Do you have a family history of any of the following?
Uterine Cancer: Yes No Family member(s):
Ovarian Cancer: Yes No Family member(s):
Fibrocystic Breast: Yes No Family member(s):
Breast Cancer: Yes No Family member(s):
Heart Disease: Yes No Family member(s):
Osteoporosis: Yes No Family member(s):
Prematurely gray: Yes No Family member(s):

Medications Previously Taken:
* 1. Have you been on hormones (natural or synthetic) previously?      Yes No
If yes, please answer the following:
Hormone: Date Started: Date Stopped: Why:
Hormone: Date Started: Date Stopped: Why:
Hormone: Date Started: Date Stopped: Why:
Hormone: Date Started: Date Stopped: Why:
Hormone: Date Started: Date Stopped: Why:
Hormone: Date Started: Date Stopped: Why:

Body Type:
* 1. What is your bone size?      Small Medium Large
* 2. What is your body type?           Androgenic Estrogenic

Contraceptives:
* 1. Have you ever used oral contraceptives?      Yes No
* 2. If yes, to using oral contraceptives, please answer the following questions:
Oral Contraceptive Used? Date Started: Date Stopped:
Oral Contraceptive Used? Date Started: Date Stopped:
Oral Contraceptive Used? Date Started: Date Stopped:
Oral Contraceptive Used? Date Started: Date Stopped:
* 3. Did you have any problems using oral contraceptives?      Yes No
If yes, please describe any problem(s):

Natural Hormone Replacement:
* 1. How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?

Doctor Self Friend or Family Member Other,      
please describe

* 2. What are your goals with taking Bio-Identical Hormone Replacement Therapy?

Pregnancy:
* 1. How many pregnancies have you had?       
* 2. How many children?       
* 3. Any Complications?       
* 4. Any interrupted pregnancies? Yes No If yes, how many?
* 5. Have you had a hysterectomy? Yes No Date of Surgery?
* 6. Have you had your ovaries removed? Yes No Date of Surgery?
* 7. Are your ovaries intact? Yes No Date of Surgery?
* 8. Have you had tubal ligation? Yes No Date of Surgery?
* 9. Have you used birth control pills? Yes No How long?

Symptoms:
* 1. If you have experienced any of the following symptoms please place a number in the appropriate area.
  0 = Rarely a Problem
1 = Mild
2 = Moderate
3 = This is serious for me
     Headache    Difficulty Concentrating    Night Sweats    Cramps
     Heart Palpitations    Fibrocystic Breasts

   Feeling of Depression

    Anxiety
     Weight Gain    Vaginal Dryness    Yeast Infections    Moodiness
     Uterin Fibroids    Swollen Breasts    Food Cravings    Bloating
     Dry Hair or Skin    Loss of Pubic Hair    Low Body Temperature    Irritability
     Hot Flashes    Hair Loss    Painful Intercourse    Mood Swings
     Increased Facial Hair    Difficulty Sleeping    Shortness of Breath    Fatigue
     Urinary Tract Infections    Foggy Thinking    

* 2. Check any of the following you experienced.
Heart Trouble High Blood Pressure Stroke Varicose Veins Clotting Problems
Diabetes Kidney Trouble Epilepsy Fractures Arthritis
Colitis Gallbladder Trouble Asthma Chronic Fatigue Fibromyalgia
Eating Disorder Digestion Problems Cancer Multiple Sclerosis  

Sample:    Date - Tuesday, February 23 (First day of menstrual flow is day 1 of cycle).

• Indicate symptom severity:    0 = No Symptom    X = Moderate Symptoms    S= Severe Symptoms
• Indicate menstrual flow with: "M" for heavy flow and "m" for light / moderate flow.
• Indicate overall mood of the day: (scale 0-10) with 0 representing severe depression and 10 feeling fine.

Examples of PMS symptoms: abdominal bloating, acne, anxiety, backache, breast tenderness, clumsiness, crying, depression, dizziness, fainting, fatigue, fluid retention, food cravings, forgetfulness, headache, hostility, irritability, joint swelling, menatal confusion, migrane, moodswings, tension.

Sample Month
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day | Date
T-23
W-24
T-25
F-26
S-27
S-28
M-1
M-2
Irritability
o
o
o
o
o
o
o
o
o
o
o
o
x
x
S
x
x
o
o
o
o
o
o
x
x
S
S
S
o
o
o
Headache
o
o
o
o
o
o
o
o
o
o
o
o
o
x
S
x
o
o
o
o
o
o
o
o
x
S
S
S
o
o
o
Fluid Retention
o
o
o
o
o
o
o
o
o
o
o
o
o
x
S
x
o
o
o
o
o
o
o
o
x
S
S
S
o
o
o
Menses
M
M
M
M
m
Overall Mood
10
10
10
10
10
10
10
10
10
10
10
10
8
5
3
8
8
8
8
8
7
7
6
4
4
4
3
2

Click here to download Chart

Doctor Medical Release Authorization:

* Check this box after you have read and agreed to the following:

"I hereby authorize my Physician to furnish an agent of Martin Avenue Pharmacy, Inc. any and all records pertaining to my medical history, services rendered and / or treatments. I understand that employees of Martin Avenue Pharmacy, Inc. will protect my privacy and this information will be released to other health care professionals only when it is necessary in order to provide health care services to me. I further understand that a Martin Avenue Pharmacy, Inc. employee will not release this information unless authorized by me in writing. This authority shall continue until revoked by me in writing."

 
* Physician Name:
* Address:
* City:
 
* State:
* Zip Code:
* Phone:
 
Pharmacy Record Release Authorization:
I, the undersigned patient, authorize my pharmacist to release my personal medication and / or other medical information to the following persons or organizations upon request or as deemed necessary:
  Name: Address: Phone:
1.
2.
3.
4.
 

* Check this box after you have read and agreed to the following:

I understand that employees of Martin Avenue Pharmacy, Inc. will protect my privacy and this information will be released to other health care professionals only when it is necessary in order to provide health care services to me. This authority shall continue until revoked by me in writing.

 
Question Documentation Form:
Please write down any questions you may have about Prescription Natural Hormone Replacement Therapy (Rx NHRT), other medications, or any other questions that come up as you read through the materials you have received. Thank you.
1.
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Finished?