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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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