Download this form for a FREE hormone

MEDICAL HISTORY FORM
After you have completed this form please return it to Piney Point Pharmacy.
Doing so entitles you to a FREE consultation with our pharmacist George P. Tompkins.
You can return this in person, fax this form to 713-782-6535 or email it to
[email protected]
1.
Patient information:
Name:
Birth date:
Address:
City:
Zip:
Height:
Home/Work/cell Phone:
State:
Approximate Weight:
/
Gender:
/
Email Address:
2.
Lifestyle Information: Do you use?
Yes or No
If yes how often/how much
Tobacco (smoke, chew or snuff)
Alcohol (beer, wine or hard liquor)
Caffeine (cola drinks, tea or coffee)
IMPAIRMENTS: Check if you have any of the following
Physical Impairments
Visual Impairment
EXERCISE: Do you exercise regularly?
Yes
Hearing Impairment
No
If yes, describe your routine and how often:
STRESS MANAGEMENT: Do you practice stress management techniques?
If yes, describe what and how often:
DIET: describe your typical daily food intake:
First Meal:
Second Meal:
Third Meal:
Snacks:
Yes
No
3.
Allergies: Please check all that apply:
Penicillin
Codeine
Sulfa Drug
Morphine
Aspirin
Food Allergy
Dye Allergy
Nitrate Allergy
Pet Allergy
Seasonal Pollen
None
Other
Please describe the allergic reaction you experienced and when it occurred:
4. Over The Counter (OTC) issues:
Please circle all products that you use occasionally or regularly:
Pain reliever
Aspirin
Acetaminophen(Tylenol)
Ibuprofin(Motrin IB)
Naproxen(Aleve)
Ketoprofen(Orudis KT)
Cough suppressant
Antihistamine Chlor-Trimeton
Decongestant(Sudafed)
Combination product(cold & cough)(Triaminic)
Sleep aides(Excedrin PM, Unisom, Sominex, ECT…)
Antidiarrheals(Imodium, Pepto Bismol)
Laxatives, stool softeners(Doxidan, Correctal, ECT…)
Diet aids/weight loss products(Dexatrim)
Antacids(Maalox, Mylanta)
Acid blockers(Tagamet HB, Pepcid AC, Zantac, ECT…)
Other(Please list)
Nutritional/natural supplements: Please identify and list the products you are using.
Vitamins (multiple or single vitamins such as B Complex, E, C, Beta carotene):
Minerals (Calcium, magnesium, chromium, colloidal minerals, ECT…)
Herbs (Ginseng, Ginkgo Biloba, Echinacea, herbal teas, tinctures, remedies)
Enzymes (digestive formulas, papaya, Bromelain, Coenzyme Q10, ECT…)
Nutrition/protein supplements (Shark cartilage, protein powders, amino acids, fish oils, ECT…)
Others ( Glucosamine, ECT…)
5.
Medical conditions/diseases. Please circle all that apply to you.
Heart disease (congestive heart failure)
High cholesterol or lipids (Hyperlifpidemia)
High blood pressure (Hypertension)
Cancer
Ulcers (stomach, esophagus)
Thyroid disease
Hormonal related issues
Blood clotting problems
6.
Lung Conditions (asthma, COPD, ECT…)
Diabetes
Arthritis or joint problems
Depression
Epilepsy
Headaches/migraines
Eye disease (Glaucoma, ECT…)
Other: Please list
Prescription Medications:
Please list prescription medications you are currently using. Be sure to include any mail order or physician samples
your are receiving.
Medication:
Dose:
Times a Day:
Doctor:
PART TWO OF THIS FORM WILL FOLLOW:
Once you have finished this evaluation and returned it to Piney Point Pharmacy make sure to ask about our H.H.P.
program designed to save money and increase one’s quality of life.
Piney Point Pharmacy is here for you!
Remember FREE delivery or next day UPS service is available.
Call 713-782-6212 or 888-730-3784 for details
1.
How did you arrive at the decision to consider Prescription Natural Hormone Replacement Therapy?
Please Circle:
Doctor
Self
2.
Friend/family member
periodical/advertisement
Bone size
Small
Medium
3.
Large
Body type
Androgenic
Estrogenic
4. Have you ever used oral contraceptives?
Yes
No. If yes, any problem and
describe.
5. How many pregnancies have you had?
6. Have you had a hysterectomy?
How many children?
Yes
No
Yes
No
If yes, date of surgery?
7. Have you had tubal ligation?
7.
Do you have a family history of any of the following? Circle all that apply.
Uterine cancer
Ovarian cancer
Osteoporosis
Heart Disease
Breast cancer
8.
Were you prematurely grey?
Yes
No
9.
Have you had any of the following tests performed? Circle those that apply & note date of last test.
Mammography
Yes
No
Date
PAP Smear
Yes
No
Date
10. Since you first began having periods have you ever had what you would consider to be abnormal
Cycles?
Yes
No, if yes please explain (such as age when this occurred,
ECT…)
11A. When was your last period?
How many days did it last?
11. Do you have, or have you ever experienced Premenstrual Syndrome (PMS)
Yes
Name:
No
Please explain symptoms.
Have you experienced any of the following symptoms recently? Please circle the number that best describes
your experiences, with one being extremely mild and ten being extremely severe.
Sleep disruptions
1
2
3
4
5
6
7
8
9
10
Fatigue
1
2
3
4
5
6
7
8
9
10
Vaginal dryness
1
2
3
4
5
6
7
8
9
10
Irritability
1
2
3
4
5
6
7
8
9
10
Nervousness
1
2
3
4
5
6
7
8
9
10
Breast tenderness
1
2
3
4
5
6
7
8
9
10
Hot flashes
1
2
3
4
5
6
7
8
9
10
Dry Skin
1
2
3
4
5
6
7
8
9
10
Mood swings
1
2
3
4
5
6
7
8
9
10
Arthritis
1
2
3
4
5
6
7
8
9
10
Loss of recent memory
1
2
3
4
5
6
7
8
9
10
Weight gain
1
2
3
4
5
6
7
8
9
10
Decreased sex drive
1
2
3
4
5
6
7
8
9
10
Depression
1
2
3
4
5
6
7
8
9
10
Fluid retention
1
2
3
4
5
6
7
8
9
10
Headaches
1
2
3
4
5
6
7
8
9
10
Night sweats
1
2
3
4
5
6
7
8
9
10
Hair loss
1
2
3
4
5
6
7
8
9
10
Harder to reach climax 1
2
3
4
5
6
7
8
9
10
Bladder Symptoms
1
2
3
4
5
6
7
8
9
10
Other: explain
1
2
3
4
5
6
7
8
9
10
REMEMBER, RETURN THIS FORM TO PINEY POINT PHARMACY FOR A FREE CONSULTATION,
ENROLLMENT IN OUR H.H.P. PROGRAM TO SAVE YOU MONEY AND TO RECEIVE FREE
DELIVERY OR NEXT DAY UPS SERVICE ON ALL YOUR HORMONE PRESCRIPTIONS
713-782-6212, 888-730-3784, fax 713-782-6535, [email protected]
www.pineypointpharmacy.com