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

Month Day Year
Date
Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Age
Address *

Street Address

Street Address Line 2

City State / 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?

YES NO
How often and how much?
Do you use alcohol?

YES NO
How often and how much?
Do you use caffeine?

YES NO
How often and how much?
Do you Exercise?

YES NO
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)?

YES NO
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?

YES NO
If YES, please explain:
Have you had a tubal ligation?

YES NO
If YES, date of surgery:

Month Day Year
Have you had a hysterectomy?

YES NO
If YES, date of surgery:

Month Day Year
Reason for surgery:
Do your ovaries remain?

Yes No
Do you have a family history of any cancers or osteoporosis?

YES NO
Please list the family member(s):
EX: Mother - Breast Cancer
Have you had any of the following test performed?
Mammography

YES NO
Date:

Month Day Year
Outcome:
PAP Smear

YES NO
Date:

Month Day Year
Outcome:
Bone Density

YES NO
Date:

Month Day Year
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?

YES NO
Have you ever had what YOU would consider to be abnormal cycles?

YES NO
If YES, please explain:
When was your last period?

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

YES NO
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 Name Last Name
Phone
Address

Street Address

Street Address Line 2

City State / Province

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

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Confidential Female Hormone Evaluation

Have you had any of the following test performed?

Doctor that we should contact for this therapy: