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| Date:
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| Name:
Age:
Birth date:
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| City
State/Province
Zip/Postal code:
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| Email*:
Home Phone:
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| Work Phone:
FAX:
Occupation:
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| What is your greatest need or problem? (List the most important; then list other issues in order of importance): |
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| Your current medical conditions or diagnoses: |
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| Drug allergies: |
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| Allergies to food, pollens, environment, etc: |
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| Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them: |
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Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other: |
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| Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using: |
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| If you are you currently taking medication for a thyroid condition, which one and dose? |
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| Have you ever had a bone density scan?
Yes
No When?
Results
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| Do you use tobacco products?
Yes
No |
| What?
How Much?
For How Long?
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| Do you use alcohol products?
Yes
No |
| What?
How Much?
For How Long?
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| Do you use caffeine products?
Yes
No What?
How Much?
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| Do you use recreational drugs?
Yes
No What?
How Much?
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| How much water do you drink in one day (24 hr)? |
oz.
glasses. |
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| Is your drinking water from a:
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home well
city water
distilled water
bottled water
water purifier |
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| Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc): |
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| When was your last: General medical exam:
Pelvic exam:
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| Have you ever had an abnormal Pap?
Yes
No When?
Treatment:
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| At what age was your First Period (menarche)?
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| When was your most recent or last period (LMP):
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| Do you still have your period? |
Yes
No |
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| If Yes, how many days from the start of one period to the start of the next? |
days |
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| Number of days of flow: |
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| Amount of bleeding: |
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| Describe any cramping or pain you may have: |
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| Do you have pain at any other time in your cycle? |
Yes
No |
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where, when, how long?
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| Any current changes in your normal cycle? |
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| Any bleeding between periods (IMB): |
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| When and describe: |
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| What were your periods like as a teenager? |
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| If you have ever had Premenstrual Symptoms (PMS), please describe: |
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| How long have you had PMS symptoms? |
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| Starting and ending when: |
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| If your periods have ever been difficult, irregular, or abnormal in any way, please describe: |
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| If you are you currently having any pelvic pain, pressure, or fullness, describe: |
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| Describe any recent unusual vaginal discharge or itching: |
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| Treatment for any of above: |
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| Have you had any of the following surgeries? |
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| Tubes tied (tubal ligation)? |
Yes
No When?
and at what age?
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| Uterus removed (hysterectomy)? |
Yes
No When?
Why?
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| Ovaries removed (oophorectomy)? |
Yes
No PART
If Yes or PART, What?
When:
Why?
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| Were there any problems associated with the surgery or removal of any of these organs? |
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| Has your doctor diagnosed menopause, or told you that you are in menopause? |
Yes
No If Yes, at what Age?
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| If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed? |
Yes
No |
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| Have you ever been pregnant? |
Yes
No |
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| Are you trying to get pregnant? |
Yes
No |
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| What was your age at your first pregnancy? |
Any problems?
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| How many times have you been pregnant (gravida)? |
How many pregnancies resulted in the birth of living children (para)?
Were there any problems?
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| Any interrupted pregnancies (miscarriages or abortions)? |
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| Current birth control method: |
How long:
Any problems?
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| Have you ever used any of the following birth control methods: |
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| Oral Contraceptives (Birth Control Pills) |
Yes
No Total months/years used:
Describe any side effects to Birth Control Pills:
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| Intra-Uterine Device (IUD) |
Yes
No Problems?
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| When was your last mammogram? |
Results:
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| Do you examine your breasts monthly? |
Yes
No |
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| Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details: |
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| Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions? |
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| If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results: |
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CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.
0 = None (symptom not present)
1 = Mild (present but not distressing)
2 = Moderate (distressing, but not interfering with daily life)
3 = Severe (very distressing, interferes with daily life)
If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you. |
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| Hot flushes |
0
1
2
3 |
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| Night sweats |
0
1
2
3 |
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| Light-headed feelings/dizziness |
0
1
2
3 |
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| Headaches |
0
1
2
3 |
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Sleep disorders/Sleeplessness |
0
1
2
3 |
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| Unusual tiredness/Fatigue |
0
1
2
3 |
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Irritability |
0
1
2
3 |
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| Depression |
0
1
2
3 |
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| Anxiety/Tension/Nervousness |
0
1
2
3 |
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| Mood swings/Mood changes |
0
1
2
3 |
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| Confusion/Difficulty concentrating |
0
1
2
3 |
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| Forgetfulness/Short-term memory loss |
0
1
2
3 |
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| Angry outbursts/Arguments/ Violent tendencies |
0
1
2
3 |
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| Crying easily |
0
1
2
3 |
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| Backache |
0
1
2
3 |
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| Joint pains |
0
1
2
3 |
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| Muscle pains |
0
1
2
3 |
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| Muscle cramps/spasms |
0
1
2
3 |
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| Problems with wound healing time |
0
1
2
3 |
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| Acne/Pimples/Skin flushing |
0
1
2
3 |
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| New facial hair |
0
1
2
3 |
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| Dry skin/Dry hair |
0
1
2
3 |
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| Crawling feeling under skin |
0
1
2
3 |
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Frequent Urinary Tract Infection (UTI) |
0
1
2
3 |
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| Urinary frequency |
0
1
2
3 |
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| Vaginal dryness |
0
1
2
3 |
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| Abnormal bleeding |
0
1
2
3 |
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| Pelvic pain, pressure, fullness, or bloating |
0
1
2
3 |
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| Uncomfortable intercourse |
0
1
2
3 |
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| Loss of sexual feeling/desire |
0
1
2
3 |
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| Loss of arousability & capacity for orgasm |
0
1
2
3 |
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| Loss of sexual sensitivity |
0
1
2
3 |
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| Loss of vitality |
0
1
2
3 |
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| Nipple sensitivity |
0
1
2
3 |
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| Discharge or leaking from nipples |
0
1
2
3 |
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| Breast tenderness |
0
1
2
3 |
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| Loss of pubic hair |
0
1
2
3 |
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| Swelling of hands, ankles, or breasts |
0
1
2
3 |
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| Heart palpitations |
0
1
2
3 |
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| Shortness of breath |
0
1
2
3 |
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| Food /sweets /salt cravings |
0
1
2
3 |
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| Increased appetite/weight gain |
0
1
2
3 |
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| Tightness in neck/shoulders |
0
1
2
3 |
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| Visual disturbance or decreased vision |
0
1
2
3 |
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| Difficulty hearing |
0
1
2
3 |
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| Diminished sense of taste |
0
1
2
3 |
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| Diminished sense of smell |
0
1
2
3 |
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(Type the 5 alphanumeric figures on the left image.)
Can't see the code clearly?
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