Confidential Hormone Evaluation

CARE . WELLNESS . COMPOUNDING

Once completed and submitted, our Hormone Specialty Pharmacists will review the information and evaluate if further testing (such as Saliva Hormone Testing) should be performed. Please note this evaluation is kept strictly confidential and is accessed only by the professional staff at Greenhill Pharmacy.

Medical History

Date
Name *enter full name
Birthdate *
Age
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email *
Gender *
Height *
Weight *
Do you use tobacco:
How often and how much?
Do you use alcohol?
How often and how much?
Do you use caffeine?
How often and how much?

Doctor's info

Doctor's Name *
Doctor's Phone *
Street Address
City
State
Zip Code

Allergies and Medications

Allergies: Please check all that apply
penicillincodeinesulfa drugmorphineaspirinfood allergiesdye allergiesnitrate allergypet allergiesseasonal (pollen) allergiesno know allergies
Any other allergies not listed from above?
Pleae describe the allergic reaction you experienced and when it occured?
Over-the-counter (OTC): Please check all products that you use occasionally or regularly. Check all that apply
Pain RelieverAspirinAcetaminophen (example: Tylenol®)Ibuprofen (example: Motrin IB®)Naproxen (example: Aleve®)Ketoprofen (example: Orudis KT®)Cough suppressant (example: Robitussin DM®)Antihistamine product (example: Chlor-Trimeton®)Decongestant product (example: Sudafed ®)Combination product (cough+cold reliever)(example: Triaminic DM®)Sleep aids (exmples: Excedrin PC®, Unisom®, Sominex®, Nytol®)Antidiarrheals (examples:Imodium®, Pepto Bismol®, Kaopectate®)Laxatives/stool softeners (examples: Doxidan®, Correctol®, etc.)Diet aids/weight loss products (example: Dexatril®)Antacids (examples: Maalox®, Mylanta®)Acid blockers (examples: Tagamet HB®, Pepcid C®, Zantac 75®)
Any other products not listed from above?
Nutritional/Natural Supplements: Please identify and list the products you are using:
vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene)minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals)herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.)enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.)
Any others not listed from above? (glucosamine, etc.)

Medical History continued...

Medical Conditions/Diseases: Please check all that apply to you.
Heart disease (example: Congestive Heart Failure)High cholesterol or lipids (examples: Hyperlipidemia)High blood pressure (example: Hypertension)CancerUlcers (stomach, esophagus)Thyroid diseaseHormonal Related IssuesLung condition (example: asthma, emphysema, COPD)Blood Clotting ProblemsDiabetesArthritis or joint problemsDepressionEpilepsyHeadaches/migrainesEye Disease (glaucoma, etc.)
Please list any other not listed from above.
Please list your current prescription medications by medication name, strength, date started, and how often per day.
Please list hormones previously taken by date started, date stopped, and the reason.
Bone Size
Body Type
Have you ever used oral contraceptives?
Any problems?
If YEs, describe any problem(s).

Female Related Questioning

How many pregnancies have you had?
How many children?
Any interrupted pregnancies?
Have you had a hysterectomy?
Ovaries removed?
If Yes, when was the date of the surgery?
Have you had a tubal ligation?
If yes, when was the date?
Do you have a family history of any of the following? Check all that apply.
Uterine CancerOvarian CancerFibrocystic breastBreast CancerHeart DiseaseOsteoporosis
If you checked any of the options, please tell us which family members had what.
Have you had a Mammography performed?
If Yes, when was the date performed?
Have you had a PAP Smear performed?
If Yes, when was the date performed?
Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles?
If Yes, can you give us a date?
If Yes, to the above question, please explain (such as age when this occurred, symptoms....)
When was your last period?
How many days did it last?
Do you have, or did you ever have Premenstrual Syndrome (PMS)?
If Yes, please explain the symptoms.

End of Female Related Questioning

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy? *
If other, please explain.
What are your goals with taking BHRT?
Please let us know any questions you have about Bio-Identical Hormone Replacement Therapy.

Hormone Replacement Therapy Patient Information

Please rate your symptoms below for the product.
Fibrocystic Breast
AbsentMildModerateSevere
Weight Gain
AbsentMildModerateSevere
Heavy/Irregular Menses
AbsentMildModerateSevere
Hot Flashes
AbsentMildModerateSevere
Dry Skin/Hair
AbsentMildModerateSevere
Anxiety
AbsentMildModerateSevere
Depression
AbsentMildModerateSevere
Night Sweats
AbsentMildModerateSevere
Vaginal Dryness
AbsentMildModerateSevere
Headaches
AbsentMildModerateSevere
Irritability
AbsentMildModerateSevere
Mood Swings
AbsentMildModerateSevere
Breast Tenderness
AbsentMildModerateSevere
Sleep Disturbances/Insomnia
AbsentMildModerateSevere
Cramps
AbsentMildModerateSevere
Fluid Retention
AbsentMildModerateSevere
Breakthrough Bleeding
AbsentMildModerateSevere
Fatigue
AbsentMildModerateSevere
Loss of Memory
AbsentMildModerateSevere
Bladder Symptoms
AbsentMildModerateSevere
Arthritis
AbsentMildModerateSevere
Harder to Reach Climax
AbsentMildModerateSevere
Decreased Sex Drive
AbsentMildModerateSevere
Hair Loss
AbsentMildModerateSevere

Verification

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