Rx3 Compounding - Online Women's Medical History Form

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
Should be Empty:

Online Women's Medical History Form - Rx3 Compounding Pharmacy

Patient Information

Medications/Supplements

Medical History

Social History

Rating of Symptoms

Hormone Replacement Therapy (HRT)