Women's Health Evaluation - Bedford Wellness RX

Evaluation Form

Bedford Wellness Pharmacy
CONFIDENTIAL WOMEN’S HEALTH & HORMONE EVALUATION
7473 Secor Rd.
Lambertville, MI 48144
The purpose of this evaluation & consultation is to gather information to help your doctor and pharmacist improve your health naturally by restoring hormone balance, optimizing your diet, supplementing with appropriate nutritional products, adopting an active lifestyle, avoiding environmental toxins, and using bio-identical hormones, where appropriate. It is important to note that attaining optimal health is dependent on providing honest, accurate information. Your responses will be held in strictest confidentiality. They are considered protected health information and, as such, are subject to HIPAA privacy laws.
Insurance Carrier
Patient Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Mobile Phone
Email Address
Birthdate
MM
DD
YYYY
Age
How did you hear about this service (Women’s Health & Hormone Consultation)?
- Advertisement
- Doctor
- Friend/Family
- Book
- Seminar
- Other
If you Selected "Friend/Family" or "Other," please indicate the source of your referral.
What do you hope to accomplish with this Consultation? (list up to 5 items, in order of importance).
Please write down any questions you have about your health and/or hormone therapy.
Medical History
Treating Doctor's Name
First Last
(This is the doctor to whom you would like us to send the recommendation)
Treating Doctor's Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
DIET & LIFESTYLE
Do you use Tobacco?
- No
- Yes
If you answered Yes to the above question. How much per day or week is consumed?
Do you drink Alcohol?
- No
- Yes
If you answered Yes to the above question. How much per day or week is consumed?
Do you drink Caffeine?
- No
- Yes
If you answered Yes to the above question. How much per day or week is consumed?
*Please keep a detailed diary of your diet for 1 week prior to your consultation. You should not change your diet during this time. Bring this to your consultation.
Allergies (Please check all that apply):
- No known allergies
- Penicillin
- Morphine
- Dye allergies
- Pet allergies
- Codeine
- Asprin
- Nitrate allergy
- Seasonal (pollen) allergies
- Sulfa
- Food allergies
Other Allergies not listed above
Please describe the type of reaction you experienced (for each allergy) and when it occurred.
Medical Conditions (Please check all that apply to you):
- Heart disease
- Blood clotting problems
- High cholesterol
- Diabetes
- High blood pressure
- Arthritis or joint problems
- Cancer
- Depression
- Ulcers or GERD
- Epilepsy
- Thyroid disorder
- Headaches/migraines
- Hormone related issues
- Eye disease (glaucoma, etc.)
- Allergies and/or Asthma
Other conditions not listed above (Please list)
Family History
List family members who have had the following conditions
Uterine Cancer
Ovarian Cancer
Fibrocystic Breast
Breast Cancer
Heart Disease
Osteoporosis
Stroke
Diabetes
Other Cancer (list)
Current Prescription Medications (including current hormones)
List Medication Name, Strength, Quatity taken per day, and Date started
List Hormones previously taken (including birth control)
List Hormone Name, Strength, Quatity taken per day, Date started, Date Stopped, and Reason for stopping (if applicable)
** Over-the-counter (OTC) product notice **: Bring these items to your consultation. Please bring all items, whether taken regularly or just occasionally, including (but not limited to) vitamins, supplements, herbal remedies, homeopathic preparations, cold & cough products, antacids, bowel products, pain relievers.
OB/GYN History
When was your last period?
How many days did it last?
Have you ever had what you consider to be abnormal cycles?
- No
- Yes
If you answered yes, when did this cycle happen?
If you answered yes, what symptoms did you have?
Have you ever suffered from Premenstrual Syndrome (PMS)?
- No
- Yes
If you answered yes, when did this cycle happen?
If you answered yes, what symptoms did you have?
How often do you have bowel movements?
(Per day, per week, or per month)
How many pregnancies have you had?
How many children?
Have you had a hysterectomy?
- No
- Yes
Date of the Surgery
Reason for the Surgery
Ovaries removed?
- No
- Yes
Have you had a tubal ligation?
- No
- Yes
Date of the Surgery
Please list the dates of your last exam(s):
Mammogram:
Pelvic (PAP Smear):
Please list any other pertinent information about your health:
Symptoms Checklist
Hot Flashes
- Absent
- Mild
- Moderate
- Severe
Night Sweats
- Absent
- Mild
- Moderate
- Severe
Vaginal Dryness
- Absent
- Mild
- Moderate
- Severe
Painful Intercourse
- Absent
- Mild
- Moderate
- Severe
Incontinence
- Absent
- Mild
- Moderate
- Severe
Irregular Bleeding
- Absent
- Mild
- Moderate
- Severe
Uterine Fibroids
- Absent
- Mild
- Moderate
- Severe
Water Retention
- Absent
- Mild
- Moderate
- Severe
Weight Gain
- Absent
- Mild
- Moderate
- Severe
Tender Breasts
- Absent
- Mild
- Moderate
- Severe
Fibrocystic Breast
- Absent
- Mild
- Moderate
- Severe
Depression
- Absent
- Mild
- Moderate
- Severe
Forgetful
- Absent
- Mild
- Moderate
- Severe
"Foggy" Thinking
- Absent
- Mild
- Moderate
- Severe
Tearful
- Absent
- Mild
- Moderate
- Severe
Mood Swings
- Absent
- Mild
- Moderate
- Severe
Headaches
- Absent
- Mild
- Moderate
- Severe
Stress
- Absent
- Mild
- Moderate
- Severe
Morning Fatigue
- Absent
- Mild
- Moderate
- Severe
Evening Fatigue
- Absent
- Mild
- Moderate
- Severe
Difficulty Sleeping
- Absent
- Mild
- Moderate
- Severe
Decreased Stamina
- Absent
- Mild
- Moderate
- Severe
Anxious
- Absent
- Mild
- Moderate
- Severe
Irritable
- Absent
- Mild
- Moderate
- Severe
Nervous
- Absent
- Mild
- Moderate
- Severe
Dizzy Spells
- Absent
- Mild
- Moderate
- Severe
Sugar Cravings
- Absent
- Mild
- Moderate
- Severe
Cold Body Temperature
- Absent
- Mild
- Moderate
- Severe
Hoarse Voice
- Absent
- Mild
- Moderate
- Severe
Goiter
- Absent
- Mild
- Moderate
- Severe
Dry/Brittle Hair, Nails, or Skin
- Absent
- Mild
- Moderate
- Severe
(including hair loss)
Constipation
- Absent
- Mild
- Moderate
- Severe
Slow Pulse
- Absent
- Mild
- Moderate
- Severe
Heart Palpitations
- Absent
- Mild
- Moderate
- Severe
Fertility Problems
- Absent
- Mild
- Moderate
- Severe
Decreased Sex Drive
- Absent
- Mild
- Moderate
- Severe
Difficulty Reaching Climax
- Absent
- Mild
- Moderate
- Severe
Decreased Muscle/Strength
- Absent
- Mild
- Moderate
- Severe
Aches & Pains
- Absent
- Mild
- Moderate
- Severe
Signs of Aging
- Absent
- Mild
- Moderate
- Severe

Women’s Health Evaluation

Evaluation Form

Medical History

DIET & LIFESTYLE

Family History

Current Prescription Medications (including current hormones)

List Hormones previously taken (including birth control)

OB/GYN History

Please list the dates of your last exam(s):

Symptoms Checklist