Confidential Medical History Form for Women "*" indicates required fields Step 1 of 7 14% Please fill out the form below and one of our trained hormone consultants will review your information and contact you. Date MM slash DD slash YYYY First Name*Last Name*Date of Birth (M/D/Y) MM slash DD slash YYYY Phone (H/C)Phone (W)Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Preferred Method of ContactHeightWeightAgePlease enter a number from 13 to 113.How did you hear about us?Accept Evaluation Fee* Please note there is a $120.00 Evaluation Fee for each patient/history form. Please initial here for your acceptance and understanding of this fee. Our team will reach out to you to collect payment before evaluating. Initials* Info about Practitioner Referring Practitioner`s namePhoneFamily PractitionerPhoneGynocologistPhone AllergiesPlease check all that apply Food allergies Seasonal (pollen) Dye allergies Pet allergies Codeine Aspirin Penicillin Morphine Nitrate allergies Sulfa drug No known allergies Other Please describe the allergic reaction you experienced and when it occurredOver-the-counter (OTC)Please check all products that you occasionally or regularly use Pain reliever Diet Aids/ weight loss products (ex: Dexatrim) Aspirin Ketoprofen (ex: Orudis KT) Sleep aid (ex: Excedrin PM, Unisom, Somine) Antacids (ex: Maalox, Mylanta) Ibuprofen (ex: Advil, Motrin) Cough Suppressants (ex: Robitussin DM) Antidiarrheals (ex: Imodium, Pepto-Bismol, Kaopectate) Antihistamines (ex: Zyrtec, Allegra, Claritin) Naproxen (ex: Advil) Decongestant products (ex: Sudafed) Other Other Over-the-counter (OTC) (please list)Please list all supplements and doses Add Remove Nutritional Health: Do you use/ consume any of the following? (Please indicate quantity and how often.) TobaccoAlcoholCaffeineProteinFruits/ vegetablesSimple carbsSweetsDo you exercise? Yes No How often and what kind of exercise? Medical Conditions/Diseases; please check all that apply to you Irritable Bowel Chronic Fatigue Heart Disease (ex: Congestive Heart Failure) Lung Condition (ex: asthma, emphysema, COPD) High Cholesterol or Lipids (ex: Hyperlipidemia) Diabetes High Blood Pressure (ex: Hypertension) Arthritis or Joint Problems Cancer Depression Ulcers (stomach, esophagus) Epilepsy Thyroid Disease Headaches/ Migraines Hormone Related Issues Eye Disease (glaucoma, etc.) Blood Clotting Issues Autoimmune Eating Disorder Fibromyalgia Gallbladder Clotting issues Osteopenia Others, please list: Other Medical Conditionals/DiseasesFamily Member(s) with Irritable BowelFamily Member(s) with Chronic FatigueFamily Member(s) with Heart Disease (ex: Congestive Heart Failure)Family Member(s) with Lung Condition (ex: asthma, emphysema, COPD)Family Member(s) with High Cholesterol or Lipids (ex: Hyperlipidemia)Family Member(s) with DiabetesFamily Member(s) with High Blood Pressure (ex: Hypertension)Family Member(s) with Arthritis or Joint ProblemsFamily Member(s) with CancerFamily Member(s) with DepressionFamily Member(s) with Ulcers (stomach, esophagus)Family Member(s) with EpilepsyFamily Member(s) with Thyroid DiseaseFamily Member(s) with Headaches/ MigrainesFamily Member(s) with Hormone Related IssuesFamily Member(s) with Eye Disease (glaucoma, etc.)Family Member(s) with Blood Clotting IssuesFamily Member(s) with AutoimmuneFamily Member(s) with Eating DisorderFamily Member(s) with FibromyalgiaFamily Member(s) with GallbladderFamily Member(s) with Clotting issuesFamily Member(s) with OsteopeniaFamily Member(s) with Other Medical Conditions/IssuesCurrent Prescription MedicationsMedications NameStrengthDate StartedHow Often Used Per Day Add RemoveList Hormones previously takenHormone NameDate StartedDate EndedReason Add RemoveHave you ever used oral contraceptives? Yes No Did you encounter any problems during the time taken? Yes No Problems encounteredHow many pregnancies have you had?How many children?Any interrupted pregnancies? Yes No How many interrupted pregnancies have you had?Age during first pregnancy?Age during last pregnancy? Have you had a hysterectomy? Yes No Hysterectomy date MM slash DD slash YYYY Have you had your ovaries removed? Yes No Ovaries removal date MM slash DD slash YYYY Have you had a tubal ligation? Yes No Tubal ligation date MM slash DD slash YYYY Have you had a uterine ablation? Yes No Uterine ablation date MM slash DD slash YYYY Do you have a family history of any of the following? Uterine cancer Yes Family Member(s) with Uterine cancerOvarian cancer Yes Family Member(s) with Ovarian cancerBreast cancer Yes Family Member(s) with Breast cancerFibrocystic breasts Yes Family Member(s) with Fibrocystic breastsHeart disease Yes Family Member(s) with Heart deseaseOsteoporosis Yes Family Member(s) with Osteoporosis Have you had any of the following tests performed? Mammography Yes No Mammography date MM slash DD slash YYYY Mammography outcomePap smear Yes No Pap smear date MM slash DD slash YYYY Pap smear outcomeBone density Yes No Bone density date MM slash DD slash YYYY Bone density outcomeSince you first began having a menstrual cycle, have you ever had what YOU consider to be abnormal cycles? Yes No Abnormal cycle date MM slash DD slash YYYY Please explainWhen was your last menstrual cycle? MM slash DD slash YYYY How long did it last?Your menstrual cycles are Regular Irregular Describe your last three menstrual cyclesAny unusual vaginal discharge or itching? Yes No Please describeDo you or did you ever have Premenstrual Syndrome (PMS)? Yes No Please describe the symptoms How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy? Doctor Self Friend/ family Other Have you discussed BHRT with your practitioner? Yes No What are your goals with taking BHRT?How much time per week do you allow for yourself?Have you experienced a major trauma or loss in the last five years? Yes No Please provide details if you feel comfortable Have you experienced any of these symptoms in the last 6 months? Please check the number that best describes your experiences with ‘0’ being none ‘1’ being mild ‘2’ being moderate ‘3’ being severe. Salt cravings 0 1 2 3 Nervousness/anxiety 0 1 2 3 Heavy/Irregular Cycle 0 1 2 3 Stress 0 1 2 3 Sugar cravings 0 1 2 3 Vaginal dryness 0 1 2 3 Uterine Fibroids 0 1 2 3 Irritability 0 1 2 3 Constipation 0 1 2 3 Bleeding changes 0 1 2 3 Thinning skin 0 1 2 3 Loss of recent memory 0 1 2 3 Dry skin 0 1 2 3 Bladder symptoms 0 1 2 3 Fluid retention 0 1 2 3 Sleep disruptions 0 1 2 3 “Fuzzy” thinking 0 1 2 3 Hot flashes 0 1 2 3 Frequent UTI’s 0 1 2 3 Fatigue 0 1 2 3 Cold body temp 0 1 2 3 Night sweats 0 1 2 3 Frequent yeast infections 0 1 2 3 Painful intercourse 0 1 2 3 Chemical sensitivity 0 1 2 3 Incontinence 0 1 2 3 Bloating 0 1 2 3 Decreased sex drive 0 1 2 3 Hair loss 0 1 2 3 Breast tenderness 0 1 2 3 Fibromyalgia 0 1 2 3 Mood swings 0 1 2 3 Arthritis 0 1 2 3 Weight gain 0 1 2 3 Heart palpitations 0 1 2 3 Depression 0 1 2 3 Increased acne 0 1 2 3 Headaches 0 1 2 3 Aging of facial skin 0 1 2 3 Migraines 0 1 2 3 Dizzy/lightheaded 0 1 2 3 Any other concerns you would like to share with us?QuestionsPlease write down any questions you may have about Bio-Identical Hormone Replacement Therapy (BHRT), other medications, or anything else. One of our hormone consultants will discuss this information with you. Thank you. Add Remove