Online Women's Medical History Form - Rx3 Compounding Pharmacy
Patient Information
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Sex
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Height (Inches)
*
Weight (Pounds)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Allergies (Please also describe any allergic reactions, and when they occurred)
*
Doctor's Name
Clinic Name
Medications/Supplements
Current Prescription Medications (Please include Medication Name/Strength/Date Started/How Often Per Day)
*
Current Over-the-Counter (OTC) Medications that you use regularly
*
Current Nutritional/Natural Supplements that you use regularly
*
List Hormones previously taken (Please include Hormone Name/Date Started/Date Stopped/Reason)
Have you ever used oral contraceptives? If yes, any problems? If problems, please describe.
*
Medical History
Do you use tobacco?
Yes
No
If yes, how often & how much?
Do you use alcohol?
Yes
No
If yes, how often & how much?
Do you use caffeine?
Yes
No
If yes, how often & how much?
Medical Conditions/Diseases (Please check all that apply)
Heart Disease
Cancer
Lung Conditions
Depression
Headaches/Migraines
High Cholesterol
Ulcers
Blood Clotting Problems
Arthritis or Joint Problems
Eye Diseases (Glaucoma etc.)
High Blood Pressure
Thyroid Disease
Diabetes
Osteoporosis
Malnutrition
Insomnia
Other
Have you ever been told by a healthcare provider that you should not receive hormone therapy? If yes, please explain. required
*
How many pregnancies have you had? required
*
How may children have you had? required
*
Have you had any interrupted pregnancies?
Yes
No
Have you had a hysterectomy? If yes, date of surgery. required
Have you had a tubal ligation? If yes, date of surgery. required
Do you have a family history of any of the following?
Uterine Cancer
Ovarian Cancer
Fibrocystic Breast
Breast Cancer
Heart Disease
Osteoporosis
If you do have a family history with any of the above, if yes, what is your relationship to that family member?
Have you ever had a mammogram?
Yes
No
If yes, what was the date of the most recent one?
Have you ever had a PAP Smear?
Yes
No
If yes, what was the date of the most recent one?
Have you ever had a TSH, T4, or T3 level taken? If yes, list the most recent levels and the date.
*
Since you first began having periods, have you ever had what you would consider an abnormal cycle? If yes, please explain. required
*
When was your last period?
How many days did it last?
Do you have or did you ever have Premenstrual Syndrome (PMS)? If yes, please explain symptoms.
*
Social History
What is your current occupation or your occupation prior to retirement?
*
Describe your work or volunteer environment.
*
How many hours a week do you work or volunteer?
*
How many hours a week do you work or volunteer?
Are you satisfied with your work or volunteer situation?
*
Do your symptoms differ at work and at home?
*
Do you have trouble getting out of bed in the morning or feel fatigued during the day? If yes, please explain.
*
Who lives in your household?
*
Describe your living environment?
*
How many hours of sleep do you get each night?
*
How would you describe the quality of sleep you get?
*
How often do you eat out?
*
How would you describe your diet?
*
Do you have an exercise routine? If yes, what does it consist of?
*
Rating of Symptoms
Please indicated the symptoms you are experiencing as 0=none, 1=mild, 2=moderate, or 3=severe
Hot Flashes
*
0
1
2
3
Dizzy Spells
*
0
1
2
3
Night Sweats
*
0
1
2
3
Cold Body Temperature
*
0
1
2
3
Incontinence
*
0
1
2
3
Goiter
*
0
1
2
3
Bleeding Changes
*
0
1
2
3
Hoarseness
*
0
1
2
3
Uterine Fibroids
*
0
1
2
3
Dry or Brittle Hair
*
0
1
2
3
Water Retention
*
0
1
2
3
Nails Breaking or Brittle
*
0
1
2
3
Tender Breasts
*
0
1
2
3
Constipation
*
0
1
2
3
Fibrocystic Breasts
*
0
1
2
3
Slow Pulse Rate
*
0
1
2
3
Increased Forgetfulness
*
0
1
2
3
Rapid Heartbeat
*
0
1
2
3
Foggy Thinking
*
0
1
2
3
Heart Palpitations
*
0
1
2
3
Tearful
*
0
1
2
3
Infertility Problems
*
0
1
2
3
Depressed
*
0
1
2
3
Acne
*
0
1
2
3
Mood Swings
*
0
1
2
3
Increased Facial/Body Hair
*
0
1
2
3
Stress
*
0
1
2
3
Scalp Hair Loss
*
0
1
2
3
Morning Fatigue
*
0
1
2
3
Weight Gain-Hips
*
0
1
2
3
Evening Fatigue
*
0
1
2
3
Weight Gain-Waist
*
0
1
2
3
Difficulty Sleeping
*
0
1
2
3
High Cholesterol
*
0
1
2
3
Decreased Stamina
*
0
1
2
3
Elevated Triglycerides
*
0
1
2
3
Anxious
*
0
1
2
3
Decreased Libido
*
0
1
2
3
Irritable
*
0
1
2
3
Decreased Muscle Size
*
0
1
2
3
Nervous
*
0
1
2
3
Thinning Skin
*
0
1
2
3
Fibromyalgia
*
0
1
2
3
Ringing in Ears
*
0
1
2
3
Allergies
*
0
1
2
3
Rapid Aging
*
0
1
2
3
Headaches
*
0
1
2
3
Aches and Pains
*
0
1
2
3
Sugar Cravings
*
0
1
2
3
Bone Loss
*
0
1
2
3
Painful Intercourse
*
0
1
2
3
Vaginal Dryness/Atrophy
*
0
1
2
3
Hormone Replacement Therapy (HRT)
How did you arrive at the decision to consider HRT?
*
Doctor
Self
Friend/Family Member
Other
How did you hear about our pharmacy?
*
What are your goals with taking HRT?
*
Please write down any questions/comments you have about HRT or any other general questions
Submit
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