Consultations - Brick City Compounding

Hormone Evaluation Form
First Name*
Last Name*
Birthdate
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Sex*
- Female
- Male
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 how much?
Allergies
Please list any allergies and describe the reaction that occurred
Drug Allergies
Food Allergies
Other Allergies
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)
Use the "plus" icon to the right to add more medications.
Medication Name and Strength Date Started How Often Per Day
List Hormones Previously Taken
Use the "plus" icon to the right to add more hormones.
Medication Name and Strength Date Started Date Stopped Reason
Have you ever used oral contraceptives (birth control)?
- Yes
- No
If you experienced any problems, please describe
How many pregnancies have you had?
How many children?
Any Interrupted pregnancies?
- Yes
- No
If yes, please explain
Have you had a tubal ligation
- Yes
- No
If yes, date of surgery
Have you had a hysterectomy?
- Yes
- No
If yes, date of surgery
Reason for Hysterectomy
Do your ovaries remain?
- Yes
- No
Do you have a family history of any cancers or osteoporosis?
Please list the family member(s):
Have you had any of the following tests performed?
Mammography
- Yes
- No
Mammography Date
Mammography Outcome
PAP Smear
- Yes
- No
PAP Smear Date
PAP Smear Outcome
Bone Density
- Yes
- No
Bone Density Date
Bone Density Outcome
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
Explain
When was your last period?
How many days did it last?
Do you or have you ever suffered from Premenstrual Syndrome (PMS) symptoms?
- Yes
- No
Explain
Hot Flashes
- Absent
- Mild
- Moderate
- Severe
Night Sweats
- Absent
- Mild
- Moderate
- Severe
Vaginal Dryness
- Absent
- Mild
- Moderate
- Severe
Incontinence
- Absent
- Mild
- Moderate
- Severe
Bleeding Changes
- Absent
- Mild
- Moderate
- Severe
Fibrocystic Breast
- Absent
- Mild
- Moderate
- Severe
Weight Gain
- Absent
- Mild
- Moderate
- Severe
Fluid Retention
- Absent
- Mild
- Moderate
- Severe
Dry Skin/Hair
- Absent
- Mild
- Moderate
- Severe
Hair Loss
- Absent
- Mild
- Moderate
- Severe
Anxiety
- Absent
- Mild
- Moderate
- Severe
Depression
- Absent
- Mild
- Moderate
- Severe
Mood Swings
- Absent
- Mild
- Moderate
- Severe
Irritability
- Absent
- Mild
- Moderate
- Severe
Headaches
- Absent
- Mild
- Moderate
- Severe
Breast Tenderness
- Absent
- Mild
- Moderate
- Severe
Cramps
- Absent
- Mild
- Moderate
- Severe
Difficulty Falling Asleep
- Absent
- Mild
- Moderate
- Severe
Difficulty Staying Asleep
- Absent
- Mild
- Moderate
- Severe
Fatigue
- Absent
- Mild
- Moderate
- Severe
Loss of Memory
- Absent
- Mild
- Moderate
- Severe
Foggy Thinking
- Absent
- Mild
- Moderate
- Severe
Acne
- Absent
- Mild
- Moderate
- Severe
Arthritis
- Absent
- Mild
- Moderate
- Severe
Decreased Sex Drive
- Absent
- Mild
- Moderate
- Severe
Harder to Reach Climax
- Absent
- Mild
- Moderate
- Severe
Stress
- Absent
- Mild
- Moderate
- Severe
Other
What are your goals for taking Hormone Replacement Therapy?
Medical & Social History
Medical & Social History
- Alcohol Use
- Asthma/COPD
- Benign Prostatic Hyperplasia
- Cancer
- Cardiovascular Disease
- Depression
- Diabetes Mellitus
- Erectile Dysfunction
- High Blood Pressure
- High Cholesterol
- Insomnia
- Malnutrition
- Osteoporosis
- Tobacco Use
- Other
Please check the following that apply to you.
Please indicate if you are experiencing the following symptoms:
Fatigue
- Absent
- Mild
- Moderate
- Severe
Decreased Muscle Mass
- Absent
- Mild
- Moderate
- Severe
Loss in Muscle Strength
- Absent
- Mild
- Moderate
- Severe
Joint/Muscle Pain
- Absent
- Mild
- Moderate
- Severe
Increase in Waist Size
- Absent
- Mild
- Moderate
- Severe
Difficulty Losing Weight
- Absent
- Mild
- Moderate
- Severe
Decreased Height
- Absent
- Mild
- Moderate
- Severe
Decreased Sex Drive
- Absent
- Mild
- Moderate
- Severe
Difficulty Establishing and/or Maintaining Full Erections
- Absent
- Mild
- Moderate
- Severe
Decrease in Spontaneous Early Morning Erections
- Absent
- Mild
- Moderate
- Severe
Changes in Sleep Patterns
- Absent
- Mild
- Moderate
- Severe
Decreased Mental Sharpness
- Absent
- Mild
- Moderate
- Severe
Trouble Concentrating
- Absent
- Mild
- Moderate
- Severe
Less Enjoyment in Personal Interests and Hobbies
- Absent
- Mild
- Moderate
- Severe
Provider Information
Provider Name
Provider Phone
Provider Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
*** Please email or contact the pharmacy with a copy of all relevant lab work, especially hormone levels that you have recently obtained.

Medication Name and Strength	Date Started	How Often Per Day

Medication Name and Strength	Date Started	Date Stopped	Reason

Hormone Evaluation Form

Allergies

Have you had any of the following tests performed?

Medical & Social History

Please indicate if you are experiencing the following symptoms:

Provider Information