Consultation Form

Please complete as many of the questions as you can so your time is not wasted on preliminary questions and background information. Some questions are required and will be indicated by an (*). The more we know about your health history before we speak the better equipped we'll be to concentrate on what specific steps to take together to start you on a path of healthy living; free from night sweats, hot flushes/flashes and general depression. Your consultation can be done at our lab or by phone.

Patient Registration Information

Last Name* First Name* Age* mm/dd/yyyy
Address Line * City* State* Zip Code*
Daytime Phone* Home Phone Cell Phone
Email Address* Please Confirm Email*
Height
Allergies* Smoker* Alcohol* Surgeries* Feet* Inches* Weight*
Please list any allergies here: Please list surgeries you have had and the dates of each:
Please list any health problem(s) you have had including
the date and current status of problem:

Background Information – *You MUST answer as many questions as you can
Please list medications, supplements, vitamins you are taking.
Birth Control pills. Name brand. How long, when discontinued.
Premarin/Prempro. How long, when discontinued
Please summarize your diet regimen.

Please summarize your exercise regimen.

Health Questionnaire – *You MUST answer as many questions as you can
Menstrual History    
Present Status
Age Menstruation Began
Last Menstrual Period (date)    
Number of Days of Bleeding    
Still Menstruating Yes No
Regular Yes No
Pregnancies Yes No
Number of Live Births
     
Symptom    
Duration
Hot Flushes/Flashes Yes No
Headaches/Migraines Yes No
Weight Gain Yes No
Night Sweats Yes No
Insomnia-Sleep Disorders Yes No
Bloating Yes No
Depression Yes No
Forgetfulness Yes No
PMS Yes No
Mood Changes Yes No
Fatigue Yes No
Irritability Yes No
Difficulty Concentrating Yes No
Vaginal Dryness Yes No
Painful Intercourse Yes No
Decreased Sex Drive Yes No
Breast Tenderness/Soreness Yes No
Recurrent Urinary Tract Infections Yes No
Hair Thinning or Loss Yes No
Joint Tenderness/Swelling Yes No
Acne Yes No
     

If you have completed as much as possible then click the button below and your information will be emailed to our consulting BHRT pharmacist.

 

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