What is your Greatest Need or Problem? Please list all issues in order of importance
Please list any current Medical Conditions or Diagnoses:
Please list any Drug Allergies:
Please list any Other Allergies: (i.e. - food, pollens, environment, etc.)
Prescription Medications: Please list all prescription medications taken in the last 6 months, their strength, and how you take them:
Herbal Products: Please list any herbal products you have recently taken (i.e. - Evening Primrose Oil [EPO], Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc.)
Additional Vitamins, Supplements, or Medications: Please list all other vitamins, supplements, non-prescription medicines, or other OTC products you are currently using
Tobacco Use: Do you use tobacco products? Yes No
Alcohol Use: Do you use alcohol products? Yes No
Caffeine Use: Do you use caffeine products? Yes No
Recreational Drug Use: Do you use recreational drugs? Yes No
Water Intake: How much water do you drink in one day (24 hour period)?
Water Source: Where does your drinking water normally come from? Home Well City Water Distilled Water Bottled Water Water Purifier
Dietary Restrictions: Please list any dietary restrictions you may have (i.e. - salt, carbohydrates, milk products, red meat, etc.)
Bone Density Scan: Have you ever had a bone density scan? Yes No
When was your last General Medical Exam:
When was your last Pelvic Exam:
Have you ever had an Abnormal Pap? Yes No
At what age was your First Period (menarche):
When was your Most Recent or Last Period (LMP):
Your Period: Do you Still Have your Period? Yes No
Describe any Cramping or Pain you may have:
Do you have Pain at any Other Time in your Cycle? Yes No
Are there any Current Changes in your Normal Cycle: (if so, please describe)
Do you have any Bleeding between Periods (IMB): (if so, please describe)
What were your Periods like as a Teenager:
Have you ever had Premenstrual Symptoms (PMS): (if so, please describe)
How long have you had PMS Symptoms? When do they generally start and end?
Have your Periods ever been Difficult, Irregular, or Abnormal in any way: (if so, please describe)
Are you currently having an Pelvic Pain, Pressure, or Fullness: (if so, please describe)
Have you had any recent unusual Vaginal Discharge or Itching: (if so, please describe)
Have you had Treatment for any of the conditions listed above: (if so, please describe)
Have you ever had your Tubes Tied (tubal ligation)? Yes No
Have you ever had your Uterus Removed (hysterectomy)? Yes No
Have you ever had your Ovaries Removed (oophorectomy)? Yes No
Were there any problems associated with the surgery or removal of any organs:
Has your doctor diagnosed menopause, or told you that you are in menopause? Yes No
Were you ever diagnosed with Premature Ovarian Failure at or before the age of 40? Yes No
Have you ever been Pregnant? Yes No
Are you trying to get Pregnant? Yes No
What was your Age at your First Pregnancy:
How Many Times have you been Pregnant (gravida):
How Many Pregnancies resulted in the Birth of Living Children (para):
Have you had any Problems During Pregnancy: (if so, please describe)
Have you had any Interrupted Pregnancies (Miscarriages or Abortions): (if so, please describe)
Are you Currently Using Birth Control? Yes No
Have you ever used Oral Contraceptives (Birth Control Pills)? Yes No
Have you ever used an Intra-Uterine Device (IUD)? Yes No
When was your last Mammogram:
What were the Results of that Mammogram:
Do you Examine your Breasts Monthly? Yes No
Have you ever experienced Breast Pain, Discomfort, Nipple Discharge, or Swelling other than when Pregnant: (if so, please describe)
Have you ever been Diagnosed with Lumps, Fibroids, Breast Cancer, or Similar Breast Conditions: (if so, please describe)
If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:
Check the appropriate box for each symptom that best describes how you have been feeling for the past 3 weeks.
None: symptom not present Mild: present but not distressing Moderate: distressing, but not interfering with daily life Severe: very distressing, interferes with daily life
If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.
