CONFIDENTIAL FEMALE HORMONE EVALUATION

4439 Country Club Rd. Statesboro, GA. 30458

Phone (912)489-7979

Fax (912) 489-6744

Compounding@forestheightspharmacy.com
Confidential Female Hormone Evaluation
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Insurance: (You may submit a copy of your card if you prefer)

**Please Note: Compounds are rarely covered by insurance***
Insurance BIN
Insurance PCN
Insurance RX GROUP
Insurance MEMBER ID
Height
Weight
Desired Weight
Do you use tobacco?

YESNO
How often and how much?
Do you use alcohol?

YESNO
How often and how much?
Do you use caffeine?

YESNO
How often and how much?
Do you Exercise?

YESNO
How often and for how long?
Allergies: Please list any allergies and describe the reaction that occurred
Drugs*
Foods
Other
Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc.):
Current Prescription Medications (including hormones):
List Hormones Previously Taken: (Please include date started, date stopped and the reason for stopping)
Have you ever used oral contraceptives (birth control)?

YESNO
If you experienced any problems while taking oral contraceptives, please describe:
How many pregnancies have you had?
How many children?
Have you had any interrupted pregnancies?

YESNO
If YES, please explain:
Have you had a tubal ligation?

YESNO
If YES, date of surgery:

MonthDayYear
Have you had a hysterectomy?

YESNO
If YES, date of surgery:

MonthDayYear
Reason for surgery:
Do your ovaries remain?

YesNo
Do you have a family history of any cancers or osteoporosis?

YESNO
Please list the family member(s):
EX: Mother - Breast Cancer
Have you had any of the following test performed?
Mammography

YESNO
Date:

MonthDayYear
Outcome:
PAP Smear

YESNO
Date:

MonthDayYear
Outcome:
Bone Density

YESNO
Date:

MonthDayYear
Outcome
At what age did your period start?
How many days is/was your cycle?
Example: 28
Is/was your menstrual flow heavy or light?
Any Clots?

YESNO
Have you ever had what YOU would consider to be abnormal cycles?

YESNO
If YES, please explain:
When was your last period?

MonthDayYear
How many days did it last?
Do you or have you ever suffered from Premenstrual Syndrome (PMS) Symptoms?

YESNO
If YES, please explain:
What are your goals for taking Hormone Replacement Therapy?

Symptoms/Complaints

	ABSENT	MILD	MODERATE	SEVERE
HOT FLASHES
NIGHT SWEATS
VAGINAL DRYNESS
INCONTINENCE
BLEEDING CHANGES
FIBROCYSTIC BREAST
WEIGHT GAIN
FLUID RETENTION
DRY SKIN/HAIR
HAIR LOSS
ANXIETY
DEPRESSION
MOOD SWINGS
IRRITABILITY
HEADACHES
BREAST TENDERNESS
CRAMPS
DIFFICULTY FALLING ASLEEP
DIFFICULTY STAYING ASLEEP
FATIGUE
LOSS OF MEMORY
FOGGY THINKING
ACNE
ARTHRITIS
DECREASED SEX DRIVE
HARDER TO REACH CLIMAX
STRESS

OTHER SYMPTOMS OR COMPLAINTS:
Doctor that we should contact for this therapy:
Name

First NameLast Name
Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*** Please include a copy of all relevant lab work, especially hormone levels that you have recently obtained.***
Should be Empty:

Confidential Female Hormone Evaluation

Have you had any of the following test performed?

Doctor that we should contact for this therapy: