Medical History

Name*(First and Last): DOB*: Age: 
Address: 
City:  Zip:  State*:

Phone: E-mail Address*:

Gender: Male Female            Height: Weight:


Do you use tobacco? Yes No 
How often and how much do you use tabacco ?

Do you use alcohol?  Yes No 
How often and how much do you use alcohol?

Do you use caffeine? Yes No
How often and how much do you use caffeine?


Allergies: Please check all that apply.


 morphine
 dye allergies
pet allergies
 codeine  
 aspirin
 nitrate allergy
 seasonal (pollen) allergies
sulfa drug
 food allergies 
Family member(s)

Please describe the allergic reaction you experience and when it occurred:


Over-the-counter (OTC) issues:
Please check all products that you use occasionally or regularly. Check all that apply
Pain reliever                       
 Combination Product (cold+cold reliever)(example: Triaminic DM®)
Aspirin
Acetaminophen (example: Tylenol®)
Sleep aids (examples: Excedrin PC®, Unisom®, Sominex®, Nytol®)
Antidiarrheals(examples: Imodium®, Pepto Bismol® Kaopectate®)
Laxatives/stool softeners (examples: Doxidan®, Correctol ®, etc.)
Ibuprofen (example: Motrin IB®)
Naproxen (example: Aleve ®)
Diet aids/weight loss products (example: Dexatril®)
Ketoprofen (example: Orudis KT®)
Antacids (examples: Maalox®, Mylanta®)
Cough suppressant (example: Robitussin®)
Acid blockers (examples Tagamet HB®, Pepcid C®, Zantac 75 ®)
Antihistamine product (example: Chlor-Trimeton®)
Other:

Nutritional/Natural Supplements: Pleae identify and list the products you are using:
Vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene, etc.)
minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals, etc.)
herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.)
enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)
nutrition/protein supplements (examples: shark cartilage, protein powders, amino acids, fish oils, etc.)
others (glucosamine, etc.)


Medical Conditions/Diseases: Please check all that apply to you.
Heart disease (example: Congestive Heart Failure)                        Diabetes
Lung condition (example: asthma, emphysema, COPD)                 Epilepsy
High cholesterol or lipids (examples: Hyperlipidemia)                     Cancer
High blood pressure (example: Hypertension)                                Depression
Arthritis or joint problems                                                              Headaches/migraines
Ulcers (stomach, esophagus)                                                         Thyroid disease 
Hormonal Related Issues                                                               Eye Disease                   
Blood Clotting Problems 

Other:   

Current Presciption Medications:

 Medication name: Strength: Date Started: How Often:   Medication name: Strength: Date Started: How Often:
 Medication name: Strength: Date Started: How Often:   Medication name: Strength: Date Started: How Often:

List Hormones previously taken:
Hormone: Date Started: Date Stopped: Reason:    Hormone: Date Started: Date Stopped: Reason:
Hormone: Date Started: Date Stopped: Reason:    Hormone: Date Started: Date Stopped: Reason:

 Bone Size            Small         Medium          Large  

Body Type:     Androgenic      Estrogenic
         
Have you every used oral contraceptives? Yes   No  
Any problems?                                         Yes   No  

If yes, describe any problem(s)

How many pregnancies have you had?         How many chidren? 
Any interupted pregnancies?     Yes   No 
Have you had a hysterectomy? Yes   No          If yes, date of surguery 
              Ovaries removed?      Yes   No 
Have you had a tubal ligation?  Yes   No  

Do you have a family history of any of the following? Check all that apply.

 Uterine Cancer                              Family member(s)
 Ovarian Cancer                             Family member(s)
 Fibrocystic breast                          Family member(s)
 Breast Cancer                               Family member(s)
 Heart Disease                                Family member(s)
 Osteoporosis                                 Family member(s)

Have you had any of the following test performed? Check those that apply and note date of last test.
Mammography        Yes  No            Date:   :  
PAP smear              Yes  No            Date:    

Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles?             Yes    No          Date:

If YES, please explain (such as age when this occurred, symptoms….):

When was your last period?

How many days did it last?  

Do you have, or did you ever have Premenstrual Syndrome (PMS)? Yes   No  

If YES, explain the symptoms:

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?

Doctor   Self  Friend/Family Member   Other

What are your goals with taking BHRT?



Please write down any quesitons you have about Bio-Identical Hormone Replacemnet Therapy.





HORMONE REPLACEMENT THERAPY PATIENT INFORMATION SHEET