Specialty Compounding And Wellness Pharmacy

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Bio-identical Hormone Replacement Therapy Consult

Male Intake

First Name *

Last Name

Date of birth

Phone *

Address

Street Address

Country

Enter your country

State

City

Postal Code

Weight

Email *

Physician's Name

Do you have insurance?

Yes

If yes, name of insurance

ID#

MEDICAL HISTORY

Medication Allergies:

Chronic Medical Conditions:

Current Medications and Supplements:

Current Symptoms:

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Bio-identical Hormone Replacement Therapy Consult

Female Intake

First Name *

Last Name *

Date of birth

Phone *

Address

Street Address

Country

Enter your country

State

City

Postal Code

Weight

Email *

Physician's Name

Medical Insurance Type

Insurance Contract ID:

Medical Insurance Group:

Rx Insurance Bin:

Bin Contract ID:

Rx Insurance Group:

PCN:

Medication Allergies:

When was your last mammogram?

Have you had gastric bypass?

Yes

Have you had a hysterectomy?

Yes

How is it?

Complete

Partial

When

Do you still cycle?

Yes

How is your cycle?

Complete

Partial

Explain

If no cycle, how long without?

Have you had an ablation?

Yes

When

Are you currently taking birth control?

Yes

Do you currently have an IUD?

Yes

Are you currently on any type of Hormones: If yes: (we need to know what type, dose amount and when/how often taken, if they have pellets, we need to know what type (estrogen or test or both) and when it was placed last.

On your mother’s side of the family, has there been any Gynecological or female cancers? (If yes, we need to know who? What type? Hormone Receptor positive? (MUST BE SPECIFIC ON THIS)

FAMILY HISTORY

PERSONAL HISTORY

SYMPTOMS:

HOT FLASHES

NIGHT SWEATS

FOGGY THINKING

VAGINAL DRYNESS

DEPRESSION

URINARY INCONTINENCE

BLOATING

WATER RETENTION

BREAST TENDERNESS

HEADACHES

FATIGUE

MOOD/EMOTIONAL SWINGS

WEIGHT GAIN

HEAVY BLEEDING

IRRITABLE

ANXIETY

PAINFUL JOINTS

INSOMNIA/STAYING ASLEEP

LOW SEX DRIVE

PAINFUL INTERCOURSE

INABILITY TO REACH ORGASM

STRESS

MEMORY

CONFUSION

CONSTIPATION

Main Symptoms (top 3):

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Bio-identical Hormone Replacement Therapy Consult

Male Intake

MEDICAL HISTORY

Bio-identical Hormone Replacement Therapy Consult

Female Intake

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