Name
*
Date of Birth
*
 -
Month
 -
Day
Year
Date
Drivers license #
*
Address
*
Work Phone
Cell Phone
*
Email
*
Occupation
*
Relationship Status
*
Married
Single
Partnered
Divorced
Widowed
Other
How did you hear about El Dorado TrueCare Pharmacy?
What are you specific goals for this wellness evaluation?
*
Do you have specific questions about a potential therapy? (e.g Hormone Replacement Therapy)
Who is your primary healthcare provider?
*
Who is your current OB/GYN?
*
Do you have any other Medical Providers?
*
Do you have a prescription insurance card?
*
Yes
No
Maybe
If yes, who is your insurance provider(s)
What is your RX Group Number?
What is your RX ID Number?
What is the Bin#?
What is the PCN#?
Would you like to receive prescription refill reminders via text message?
*
Yes
No
Medical Status
General Health
*
Excellent
Good
Fair
Poor
Height
*
Weight
*
Goal Weight
Drug Allergies and Reaction
*
Allergies to food, chemicals, pollen, other environmental agents, etc.
Is there Cancer in the family? What type(s)? Person(s) in family?
*
Is there Diabetes in the family? What type(s)? Person(s) in family?
*
Is there Heart disease in the family? What type(s)? Person(s) in family?
*
Is there Osteoporosis in the family? What type(s)? Person(s) in family?
*
Are there any other disease states in the family? What type(s)? Person/s in family?
*
Personal Medical Conditions: (please check all that apply)
Rows
Headaches
Migraines
Stroke
Depression
Anxiety
Insomnia
Thyroid
Swollen Glands
Asthma
Heart Conditions
Clotting Defects
High Blood Pressure
Breast Lumps
Nipple Discharge
Uterine/Tubal Dysfunction
Liver Disease
Kidney Stones/Gallstones
Acid Reflux/Heartburn
Colitis, IBS, or Crohn's
Eating Disorders
Varicose Veins
Anemia
Chronic Fatigue
Fibromyalgia
Medical conditions
Do you suffer any other mood disorders? If so, what?
*
Do you have diabetes? If so, what type?
*
Do you have a Pain Condition?
If so, rate your pain.
1-10
Do you have arthritis? If so, what type?
*
Do you have fractures? If so, what type?
*
Do you have cancer? If so, what type?
*
Please list any medications, the dosages (strength), frequency and when you began taking them.
*
Please list any vitamins, the dosages (strength), frequency and when you began taking them.
If you have ever taken any past medications not listed above (i.e. for sleep, mood disorders, etc.) please list medication and doses.
Have you ever had a mammogram?
Yes
No
If yes, when and what were the results?
Have you ever had a bone density scan?
Yes
No
If yes, when and what were the results?
Have you ever had your thyroid checked?
Yes
No
If yes, when and what were the results?
Have you ever had your cholesterol checked?
Yes
No
If yes, when and what were the total results, LDL, HDL, and Triglycerides?
Gynecological History
Age at first period
Date of last period
 -
Month
 -
Day
Year
Date
Date of last pelvic examinations
 -
Month
 -
Day
Year
Date
Pap smear Results
Have you ever had an abnormal pap smear?
Yes
No
Was treatment required? If so, what?
Are you sexually active?
Yes
No
Are you trying to get pregnant?
Yes
No
Are you currently using birth control?
Yes
No
What method of birth control do you use?
How long have you used that method?
Have you had any problems with it?
If you have ever taken hormones (synthetic or natural) that are not listed above, please list medications and dosages here:
Since you started having periods:
How many days from start of one period to the start of the next?
Number of days of flow
Amount of bleeding
Heavy
Moderate
Light
Spotting
Amount of cramping
Frequent
Moderate
Infrequent
None
Premenstrual symptoms?
Starting and ending when?
Any recent changes in your normal cycle?
If so, when did the changes begin?
Any bleeding between periods?
Yes
No
Any pelvic pain, pressure, or fullness?
Yes
No
If yes, describe.
Any unusual vaginal discharge or itching?
Yes
No
If yes, describe. Was is treated? How?
Any history of vaginal yeast infections?
Yes
No
If yes, describe. Was is treated? How?
Have you taken antibiotics in the past year?
Yes
No
If yes, describe.
Check any of the following gynecological problems you have had.
Rows
Check all that apply
Vaginal Infections
Pelvic Infections
Cervical Dysplasia
HSV (Vaginal Herpes)
HPV (Vaginal Warts)
Cervical Cancer
Ovarian Cysts
Uterine Fibroids
Breast Fibroids
Age at first pregnancy?
How many full term pregnancies?
Problems?
Any interrupted pregnancies? (miscarriages)
Yes
No
Have you had a tubal ligation?
Yes
No
If yes, when?
Has your partner had a vasectomy?
Yes
No
Have you had a hysterectomy?
Yes
No
If yes, when and why?
Have you had your ovaries removed?
Yes
No
If yes, when and why?
Back
Next
Lifestyle Factors
Check the meals you eat on a daily basis:
Breakfast
Mid-morning snack
Lunch
Afternoon snack
Dinner
Last-night snack
Other
Do you eat red meat?
Yes
No
If yes, how many meals per week? What kind of red meat?
Do you drink milk?
Yes
No
If yes, how many of glasses per week or per day? What Kind?
Do you eat cheese?
Yes
No
If yes, how many times per week or per day?
Approximately how many grams of protein do you consume per day?
Do you drink coffee?
Yes
No
If yes, how many cups per week or per day?
Do you drink tea?
Yes
No
If yes, how many cups per week or per day?
Do you drink soda?
Yes
No
If yes, how many cans per week or per day? What kind?
How much water do you drink per day in ounces?
Sweets-What sweets do you usually eat and how much?
Flour-what kind and how much? (e.g. bread, pasta, pizza, baked goods, etc.)?
Sources of fat and how much (e.g. margarine, butter, cooking oils, mayo, etc.)?
How many servings of fruits do you eat per day? Vegetables?
What are your favorite foods?
What time do you usually wake up?
Hour Minutes
AM
PM
AM/PM Option
What time do you usually go to bed?
Hour Minutes
AM
PM
AM/PM Option
What is your sleep pattern (e.g. trouble falling asleep, waking at night, restless leg, racing mine)?
On average, how many hours are you asleep each night?
Do you get physical exercise?
Yes
No
If yes, what type? How often?
Do you use tobacco products?
Yes
No
If yes, how much? If previously, for how long?
Do you use Marijuana or THC Products (THC can affect hormones)?
Yes
No
Occationally
Do you use alcohol products?
Yes
No
If yes, how much? If previously, for how long?
How many bowel movements per day?
Color? Consistency?
Back
Next
Subjective Hormone Symptoms
Please rate your symptoms (0= Not at all to 5= Very Severe)
Acne
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Anxiety/Nervousness
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Apathy
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Breast Tenderness
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Brittle Nails
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Burned Out Feeling
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Chemical Sensitivities
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Cold Body Temperature
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Cold Extremities
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Confusion
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Constipation
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Cramping Abdominal
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Cravings for Sweets
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Decreased Concentration
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Decreased Sex Drive
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Decreased Sexual Sensation
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Decreased Stamina
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Deeping of Voice
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Depressed Mood
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Dry Eyes
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Dry Skin or Hair
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Fatigue
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Fibrocystic Breasts
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Fluid Retention Abdomen
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Fluid Retention Extremities
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Foggy Thinking
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Headaches
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Heart Palpitations
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Heavy and Irregular Menses
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Hoarseness
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Hot Flashes
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Hypoglycemia
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Increased Facial and / or Body Hair
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Increased Hair Loss
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Irritability
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Joint Pains
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Low Blood Pressure
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Memory Problems
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Mood Swings
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Muscle Pain
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Night Sweats
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Numbness of Hands and Feet
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Painful Intercourse
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Premenstrual Syndrome
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Salt Craving
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Sleep Disturbances
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Swollen Eyes
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Tearfulness
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Thinning Skin
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Tired but Wired
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Urinary Incontinence
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Vaginal Dryness
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Weight Gain: Hips
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Weight Gain: Waist
*
Not at all
0
1
2
3
4
Very Severe
5
0 is Not at all, 5 is Very Severe
Please list your top three complaints today:
1.
*
2.
*
3.
*
Submit
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